2023Roll no 21CBME competence based assessment of a single patient portfolio 65M joint pains back pain 10 yrs

 

6/11/2026

Here is the 6-point CBME evaluation for *2023 Batch - Roll No. 21* - Portfolio: *65M Farmer, Joint Pain - 10 Years, Back Pain - 10 Years, Stiffness Neck / MCP / Elbow, Cannot Get Up Without Support*

Based on the anonymized text you pasted. Score 0-2 per level. Total /12.

*Note on links:* You pasted 2 YouTube links at the end. I have not scored them as part of the portfolio - portfolio scoring is based on the written case. If those are meant as references for fluorosis, add a 2-line summary of what they show, not just links.

### 1. Remember - Knowledge Recall

*Evidence in portfolio:*

- Demographics with age / sex, Occupation - Farmer, chief complaints, HOPI, past history - N/K/C/O HTN, DM, Asthma, TB, Medication History - On NSAID's, Surgical History - Not significant, personal history - Diet Mixed, Sleep Disturbed, Appetite Normal, Bowel & Bladder Normal, Addictions - Beedi / Cigarette, Investigations Noted - Lateral view cervical X-ray, family history, general examination, PICCLE - Negative (-ve), vitals - Temp, PR, BP, RR, Investigations - X-ray, Patient history, systemic examination - CVS, CNS, RS, PA, On Examination - Patient has stiff knees, unable to move neck, hyperreflexia on right side of knee, Left knee reflex - Negative, Ankle reflex - Negative, Suggestive of right hemi... [as written] upper motor neuron lesion, SLR - Negative, Provisional Diagnosis - Poly osteoarthritis / Spondyloarthropathy due to fluorosis, Differential Diagnosis - Osteoarthritis, Vit D deficiency, Vit B12 deficiency.

- Good details: Joint pain both knees 10 yrs, insidious, progressive, difficulty moving joints specially in morning, stiffness of neck, metacarpal joints, elbow joint, cannot get up after sitting without support, back pain dull aching, aggravated during work, h/o wt loss. Negatives - No trauma, fever.

- Gaps: *SpO2 - Not recorded.* No BMI. No details of NSAID - name, dose, duration. No water source / fluoride exposure history despite fluorosis diagnosis. No details of wt loss - how much, over how long. X-ray findings not written - only "Lateral view cervical X-ray" listed.

*Score: 2 / 2*

- Competency met: Best documentation in Roll 21 so far - On Examination with reflexes, SLR, UMN lesion note, plus differential list.

- *Next target:* Always record SpO2, BMI. Always write X-ray findings, not just "X-ray done". Always write NSAID name + dose + duration - 10 yrs NSAID = kidney / stomach risk.

### 2. Understand - Comprehension

*Evidence in portfolio:*

- Pain pattern described - insidious, progressive, morning difficulty, dull aching back pain worse on work, cannot get up without support.

- Provisional diagnosis - Poly osteoarthritis / Spondyloarthropathy due to fluorosis.

- But no explanation in own words of why fluorosis causes polyarticular stiffness, neck stiffness, hyperreflexia.

- No explanation of hyperreflexia right knee + left knee reflex negative + ankle negative = asymmetric UMN lesion - not explained.

- No explanation of wt loss + 10 yrs joint pain - chronic disease?

*Score: 1 / 2*

- Partial comprehension.

- *Next target:* Explain: Fluorosis = excess fluoride in water -> calcification of ligaments, stiffness of spine / neck, joint pain, difficulty moving. Explain: Hyperreflexia = upper motor neuron lesion - spinal cord compression in neck due to fluorosis / spondylosis. Explain: Cannot get up without support = functional disability, quadriceps weakness + stiffness. Explain: Beedi / Cigarette + 10 yrs NSAID = risk for lung + kidney + stomach disease.

### 3. Apply - Application to Patient Care

*Evidence in portfolio:*

- Provisional diagnosis + differential list given.

- Investigations listed as X-ray, Patient history - but no X-ray findings, no labs.

- No management plan - no physiotherapy, no NSAID safety, no referral for UMN lesion.

- No application of hyperreflexia / UMN lesion to care - needs urgent neuro / spine referral.

*Score: 1 / 2*

- Partial application.

- *Next target:* Add: X-ray cervical spine + knees + LS spine findings, MRI cervical spine - cord compression?, CBC, Vitamin D, Vitamin B12, Calcium, Fluoride level in water / urine, RFT - 10 yrs NSAID, ESR / CRP, BMI. Add management - STOP self-medication with NSAIDs, physiotherapy, posture, avoid heavy work, referral - Neurology / Ortho / Spine for UMN lesion + neck stiffness, check for bladder / bowel involvement, beedi cessation, diet, follow-up. Add detailed neuro examination - power, sensation, plantar, bladder.

### 4. Analyze - Differentiation & Interpretation

*Evidence in portfolio:*

- Differential list given - Osteoarthritis, Vit D deficiency, Vit B12 deficiency, plus provisional - Poly osteoarthritis / Spondyloarthropathy due to fluorosis.

- On Examination used to support UMN lesion - hyperreflexia right knee, SLR negative.

- But no supports / against reasoning for each differential.

- No analysis of why fluorosis over OA - what evidence for fluorosis? No water source, no dental fluorosis, no ligament calcification on X-ray mentioned.

*Score: 2 / 2*

- Competency met: First time in Roll 21 you have used examination to support a diagnosis - hyperreflexia -> UMN lesion, SLR negative -> not sciatica. And you have a specific etiology - fluorosis - not just OA.

- *Next target:* Add differential table: Spondyloarthropathy due to Fluorosis - supports 65M farmer, 10 yrs, neck + knee + MCP + elbow stiffness, cannot get up without support, hyperreflexia, rural water; against - no water fluoride level, no X-ray calcification written. Osteoarthritis - supports 65M, knee pain, morning difficulty; against - MCP + elbow + neck + hyperreflexia not explained by OA alone. Vit D deficiency - supports joint + back pain, farmer; against - no Vit D level. Vit B12 deficiency - supports beedi, wt loss; against - no tingling / anemia mentioned, PICCLE negative. Must analyze: Is hyperreflexia due to cervical cord compression from fluorosis / spondylosis? Is wt loss due to chronic disease or malignancy?

### 5. Evaluate - Judgment & Reflection

*Evidence in portfolio:*

- No justification for fluorosis - no fluoride level, no X-ray findings, no water history.

- No judgment on urgency - hyperreflexia + unable to move neck + cannot get up = possible cord compression, needs urgent MRI / referral - not prioritized.

- No judgment on 10 yrs NSAID - kidney / GI risk not evaluated.

- No reflection.

*Score: 0 / 2*

- Not met.

- *Next target:* Add: Can I label fluorosis without water fluoride level or X-ray ligament calcification? What is the risk if I miss cervical cord compression in a 65M with hyperreflexia + neck stiffness? What would I do differently - ask water source, check teeth for fluorosis, ask about bladder / bowel, do MRI, stop NSAIDs, refer urgently? Reflection on polyarticular pain in farmer - OA alone does not explain neck + MCP + elbow + hyperreflexia together.

### 6. Create - Synthesis & New Learning Product

*Evidence in portfolio:*

- No original product - no algorithm, concept map, patient education material. YouTube links pasted, but no summary.

*Score: 0 / 2*

- Not met.

- *Next target:* Create 1-page algorithm: Polyarticular Pain + Neck Stiffness + Hyperreflexia -> OA vs Fluorosis vs Spondyloarthropathy -> Examination -> X-ray + MRI + Fluoride Level -> Management, OR patient education sheet for Fluorosis - water source, diet, exercises, red flags for cord compression.

### Summary Sheet - Roll No. 21 - 2023 Batch

Bloom Level | Score /2 | Key Feedback

1. Remember | 2 | Reflexes + SLR + UMN note, X-ray findings missing

2. Understand | 1 | Pain pattern described, fluorosis + hyperreflexia not explained

3. Apply | 1 | Poly OA / Fluorosis stated, no MRI / referral / NSAID safety

4. Analyze | 2 | Differential + exam used to support UMN lesion, best analysis in Roll 21

5. Evaluate | 0 | No proof for fluorosis, cord compression urgency missed

6. Create | 0 | Links pasted, no summary / no original product

**Total** | **6 / 12** | **Developing - Best in Roll 21**

*Overall CBME Feedback for Roll 21 - Progression:*

- 50F body pain + tingling / Toddy / OA + Sciatica = 4/12, 40F ankle + neck pain / Metabolic + OA + RA + Vit D = 5/12, *This portfolio = 6/12*

- *Progress improving:* Steady rise 4 -> 5 -> 6. This is your best case. You did what earlier cases missed - you examined reflexes, did SLR, noted UMN lesion, and proposed a specific cause - fluorosis - instead of just OA.

- *Critical learning from this case:* Do not waste this good examination. Hyperreflexia + unable to move neck + cannot get up without support = possible cervical cord compression. That is urgent, not routine OA. And fluorosis needs proof - water source, fluoride level, X-ray ligament calcification, dental changes. Without that, it is a hypothesis, not a diagnosis. Also, 10 years on NSAIDs with no name / dose is dangerous - check kidney, stomach, BP. Fix those three, and this case becomes 8-9/12.

2023 Roll no 21 CBME competence based assessment of a single patient portfolio 40F pain in ankle 5 mths numbness

 

5/11/2026

Here is the 6-point CBME evaluation for *2023 Batch - Roll No. 21* - Portfolio: *40F (Menopausal Age), Housewife (Cotton Factory), Ankle Pain - 5 Months with Tingling & Numbness, Neck Pain - 5 Months*

Based on the anonymized text you pasted. Score 0-2 per level. Total /12.

### 1. Remember - Knowledge Recall

*Evidence in portfolio:*

- Demographics with age / sex, Occupation - Housewife (cotton factory), note - menopausal age, chief complaints, HOPI, past history - H/o fall from bike, No similar complaints, N/K/C/O DM, Asthma, N/K/O HTN since 2 yrs, Medication - HTN drug, Surgical History - Nil, personal history - Diet Mixed, Sleep Sound, Appetite Normal, Bowel & Bladder Normal, regular, Addictions Nil, family history, general examination, PICCLE - P Positive [Pallor], I C C L E Negative, vitals - Temp, PR, BP, RR, systemic examination - CVS, RS, CNS, PA, Provisional Diagnosis - Metabolic Syndrome, Osteoarthritis, Rheumatic arthritis, Vit D deficiency, [m/c in knee way? - as written].

- Good details: Joint pain both ankles, insidious onset, gradually progressive, difficulty moving joints especially morning after waking up, aggravated during work / activities, relieved by rest, tingling & numbness. Negatives - No fever, wt loss.

- Gaps: *Medication - "HTN drug"* - name, dose not given. *SpO2 - Not recorded.* Past history contradictory - "N/K/C/O DM, Asthma (no comorbidities)" then "N/K/O HTN since 2 yrs" - confusing. No BMI / waist despite Metabolic Syndrome. No joint examination - ankle swelling, tenderness, ROM. No neuro examination - where tingling? No menopause details - LMP? No fall details - injury to ankle 2 yrs ago?

*Score: 2 / 2*

- Competency met: Best documentation in Roll 21 so far - occupation, menopausal age, surgical history, full PICCLE, systemic exam.

- *Next target:* Always write HTN drug name + dose. Always record SpO2, BMI. Always record ankle + neck examination.

### 2. Understand - Comprehension

*Evidence in portfolio:*

- Pain pattern described - insidious, progressive, morning difficulty, worse on work, better on rest.

- Provisional diagnosis list given - Metabolic Syndrome, Osteoarthritis, Rheumatic arthritis, Vit D deficiency.

- But no explanation in own words of why ankle + neck pain together, why tingling, why morning stiffness.

- No explanation of menopausal age - estrogen loss -> bone loss - not explained.

- No explanation of Pallor (+) - anemia not explained. No explanation of BP 170/100 - severe HTN - not explained.

*Score: 1 / 2*

- Partial comprehension.

- *Next target:* Explain: Menopause -> estrogen loss -> osteoporosis + OA risk, Vit D deficiency -> bone pain, joint pain. Explain: Morning difficulty = stiffness - how many minutes? Explain: Tingling & numbness = nerve involvement - cervical spondylosis / neuropathy. Explain: Cotton factory work - standing long hours -> ankle pain worsens. Explain: BP 170/100 = uncontrolled HTN, needs urgent evaluation.

### 3. Apply - Application to Patient Care

*Evidence in portfolio:*

- Provisional diagnosis list given - 4 diagnoses.

- No investigation plan, no management plan.

- No application of BP 170/100 to care - no repeat BP, no ECG, no HTN workup - despite HTN since 2 yrs.

- No application of fall from bike 2 yrs ago to care - old trauma vs new pain?

*Score: 1 / 2*

- Partial application. Diagnoses listed, but not applied to care.

- *Next target:* Add: X-ray both ankles + cervical spine, CBC - Pallor, Vitamin D, Calcium, TSH, RFT, Lipid profile, HbA1c, RA factor / Anti-CCP - Rheumatic arthritis?, ESR / CRP, BMI, Waist, ECG. Add management - for OA / Vit D: Vit D + calcium, exercises, physiotherapy, avoid prolonged standing, ankle support, posture. For HTN 170/100: repeat BP, check headache, chest pain, vision, salt restriction, review HTN drug, refer. For anemia: iron, diet. Add detailed ankle + neck + neuro examination.

### 4. Analyze - Differentiation & Interpretation

*Evidence in portfolio:*

- Differential list given - Metabolic Syndrome, Osteoarthritis, Rheumatic arthritis, Vit D deficiency - first time in Roll 21 a list is attempted.

- But no analysis of which supports / against each - just listed.

- No analysis of ankle + neck together - OA generalized vs RA vs Vit D deficiency.

- No analysis of tingling - cervical spondylosis vs neuropathy vs Vit D deficiency.

- No analysis of fall from bike 2 yrs ago - old trauma vs new disease.

*Score: 1 / 2*

- Partial analysis - list present, but no reasoning.

- *Next target:* Add differential table: Osteoarthritis - supports 40F, ankle pain, worse on work, better on rest, morning difficulty. Rheumatic arthritis / Rheumatoid Arthritis - supports ankle pain both sides, morning difficulty, neck pain; against - no swelling mentioned, need morning stiffness duration >1 hr, RA factor. Vit D deficiency - supports ankle + neck pain, menopausal age, Pallor, female, housewife indoor work; against - need Vit D level. Metabolic Syndrome - supports HTN 170/100; against - no BMI, waist, sugar, lipids. Cervical Spondylosis - supports neck pain + tingling & numbness; against - no radiation pattern. Must analyze: Is ankle pain due to old fall 2 yrs ago or new OA / RA? Is tingling due to neck or ankle?

### 5. Evaluate - Judgment & Reflection

*Evidence in portfolio:*

- No justification for 4 diagnoses - no X-ray, no Vit D level, no RA factor, no BMI / lipids to prove Metabolic Syndrome.

- No judgment on BP 170/100 - most urgent finding, not prioritized. Past history says HTN since 2 yrs, but medication name missing, BP uncontrolled.

- No judgment on "m/c in knee way?" - unclear line, not clarified.

- No reflection.

*Score: 0 / 2*

- Not met.

- *Next target:* Add: Which is most urgent - ankle pain 5 months or BP 170/100 today? What is the risk if I miss uncontrolled HTN and focus only on ankle pain? What would I do differently - repeat BP, ask HTN drug name, ask LMP / menopause age, ask morning stiffness in minutes, check ankle swelling? Reflection on ankle + neck pain in menopausal female - need to think Vit D + osteoporosis + RA together, not just OA.

### 6. Create - Synthesis & New Learning Product

*Evidence in portfolio:*

- No original product - no algorithm, concept map, patient education material.

*Score: 0 / 2*

- Not met.

- *Next target:* Create 1-page algorithm: Ankle + Neck Pain in Menopausal Female -> OA vs RA vs Vit D Deficiency -> Examination -> X-ray + Vit D + RA Factor + BP Workup -> Management, OR patient education sheet for Menopause + Bone Health - Vit D, calcium, exercises, posture.

### Summary Sheet - Roll No. 21 - 2023 Batch

Bloom Level | Score /2 | Key Feedback

1. Remember | 2 | Occupation + menopausal age + full PICCLE, HTN drug name missing

2. Understand | 1 | Pain pattern described, menopause / BP 170/100 not explained

3. Apply | 1 | 4 diagnoses listed, BP 170/100 not managed

4. Analyze | 1 | Differential list present, no supports / against reasoning

5. Evaluate | 0 | No justification, uncontrolled HTN missed

6. Create | 0 | No original product

**Total** | **5 / 12** | **Needs Support - Developing**

*Overall CBME Feedback for Roll 21 - Progression:*

- 50F housewife body pain + tingling / Toddy / OA + Sciatica = 4/12, *This portfolio = 5/12*

- *Progress improving:* First 5/12 in Roll 21. Improvement - you attempted a differential list for the first time - Metabolic Syndrome, OA, Rheumatic arthritis, Vit D deficiency - and you recorded menopausal age + cotton factory occupation + full PICCLE. That is good clinical thinking.

- *Critical learning from this case:* Listing 4 diagnoses without proof is not analysis. You need supports / against for each. And BP 170/100 is the emergency here - same trap as Roll 34's 60F with BP 180/90. HTN since 2 yrs + BP 170/100 + "HTN drug" with no name = uncontrolled HTN, medication not working or not taken. Always write drug name + dose, repeat BP, and do not label Metabolic Syndrome without BMI / waist / sugar / lipids. And "m/c in knee way?" - if you don't understand your own note, clarify it before submitting.

2023 Roll no 21 CBME competence based assessment of a single patient portfolio 50F with bodypains 5 yrs tingling sensation 2 mths

 

5/11/2026

Here is the 6-point CBME evaluation for *2023 Batch - Roll No. 21* - Portfolio: *50F Housewife, Body Pain - 5 Years, Tingling Sensation - 2 Months*

Based on the anonymized text you pasted. Score 0-2 per level. Total /12.

### 1. Remember - Knowledge Recall

*Evidence in portfolio:*

- Demographics with age / sex, Occupation - Housewife, chief complaints, HOPI, past history - N/K/C/O DM, HTN, TB, Asthma, personal history - Diet Mixed, Appetite Normal, Sleep Disturbed, Bowel & Bladder Normal, Addictions - Toddy (2 glasses / day), family history, general examination - oriented, PICCLE partially - P - Positive (+) [Pallor], I C C L E - [rest as written], vitals - BP, PR, RR, Temp, Provisional Diagnosis - Osteoarthritis + Sciatic nerve compression.

- Good details: Body pain 5 yrs, insidious onset, initially mild, gradually progressive, decreased movements especially in morning hours, aggravated during activity & relieved at rest, tingling & numbness 2 months. Negatives - No fever, wt loss, trauma.

- Gaps: *Systemic Examination - Not recorded.* PICCLE incomplete - I/C/C/L/E not given as Positive / Negative. *SpO2 - Not recorded.* No joint examination - which joints? swelling, tenderness, crepitus, ROM. No neurological examination - tingling where? legs? hands? No BMI. No duration of toddy - since when?

*Score: 1 / 2*

- Partial recall - occupation + toddy history is good, but systemic exam missing, PICCLE incomplete, SpO2 missing.

- *Next target:* Always record full PICCLE - P/I/C/C/L/E each as + / -. Always record systemic examination - CVS, RS, CNS, P/A. Always record SpO2. Always record joint + neuro examination - where is tingling, which dermatome, SLR test.

### 2. Understand - Comprehension

*Evidence in portfolio:*

- Pain pattern described - insidious, progressive, morning decreased movements, worse on activity, better on rest, tingling & numbness 2 months.

- Provisional diagnosis - Osteoarthritis + Sciatic nerve compression given.

- But no explanation in own words of why OA causes morning stiffness / decreased movements, or why sciatic compression causes tingling.

- No explanation of Toddy 2 glasses / day - alcohol causes neuropathy, nutritional deficiency - not explained.

- No explanation of Pallor (+) - anemia not explained.

*Score: 1 / 2*

- Partial comprehension.

- *Next target:* Explain: OA = cartilage loss -> pain on activity, stiffness in morning, decreased movements. Explain: Sciatic nerve compression -> tingling & numbness in leg, radiation from back to leg. Explain: Toddy - alcohol -> peripheral neuropathy, B12 deficiency, anemia -> tingling + Pallor. Explain: Morning decreased movements = stiffness - how long? OA stiffness <30 min, RA stiffness >1 hour - this distinction matters.

### 3. Apply - Application to Patient Care

*Evidence in portfolio:*

- Provisional diagnosis given as Osteoarthritis + Sciatic nerve compression.

- No investigation plan, no management plan.

- No application of toddy / Pallor to care - no alcohol cessation, no B12 / anemia workup.

- No application of tingling to care - no neuro exam, no SLR.

*Score: 1 / 2*

- Partial application.

- *Next target:* Add: X-ray joints + LS spine, CBC - Pallor, Vitamin B12, Vitamin D, Calcium, RFT, ESR / CRP, BMI. Add management - for OA: exercises, physiotherapy, avoid squatting, weight management, analgesics. For sciatica: rest, posture, physiotherapy, avoid heavy lifting, SLR test. For toddy: alcohol cessation counseling, nutrition, B12. For anemia: iron, diet. Add detailed joint + neuro examination - power, sensation, reflexes, SLR.

### 4. Analyze - Differentiation & Interpretation

*Evidence in portfolio:*

- Two diagnoses given - OA + Sciatic nerve compression - but no formal differential.

- No analysis of alternative causes: OA vs Rheumatoid arthritis vs Fibromyalgia vs Alcoholic neuropathy vs B12 deficiency.

- No analysis of morning stiffness - OA vs RA.

- No analysis of body pain + tingling together - are they same disease or two diseases?

*Score: 1 / 2*

- Partial analysis - two diagnoses listed, but not analyzed.

- *Next target:* Add differential table: Osteoarthritis - supports 50F, body pain 5 yrs, worse on activity, better on rest, morning decreased movements. Rheumatoid Arthritis - supports body pain, morning stiffness, decreased movements; against - no swelling / small joints mentioned, need morning stiffness duration. Fibromyalgia - supports body pain 5 yrs, sleep disturbed; against - no tender points. Alcoholic Neuropathy / B12 deficiency - supports tingling & numbness 2 months, Toddy 2 glasses / day, Pallor; against - need B12 level, neuro exam. Sciatic Nerve Compression - supports tingling & numbness, body pain; against - no back pain mentioned, no radiation pattern. Must analyze: Is tingling due to sciatica or alcohol neuropathy? Both possible.

### 5. Evaluate - Judgment & Reflection

*Evidence in portfolio:*

- No justification for OA + sciatic compression without X-ray / neuro exam.

- No judgment on toddy - most important modifiable factor, not evaluated.

- No judgment on Pallor - anemia not evaluated.

- No reflection, no self-assessment.

*Score: 0 / 2*

- Not met.

- *Next target:* Add: Can I label sciatic compression without back pain, radiation, SLR, neuro exam? What is the risk if I miss alcoholic neuropathy / B12 deficiency in a 50F on Toddy with tingling + Pallor? What would I do differently - ask about toddy duration, ask about back pain, radiation, ask about morning stiffness duration in minutes, do neuro exam? Reflection on body pain in housewife - impact on daily work, sleep, family.

### 6. Create - Synthesis & New Learning Product

*Evidence in portfolio:*

- No original product - no algorithm, concept map, patient education material.

*Score: 0 / 2*

- Not met.

- *Next target:* Create 1-page algorithm: Body Pain + Tingling in 50F -> OA vs RA vs Neuropathy -> Examination -> X-ray + B12 + CBC -> Management, OR patient education sheet for OA + Alcohol cessation - exercises, diet, B12, posture.

### Summary Sheet - Roll No. 21 - 2023 Batch

Bloom Level | Score /2 | Key Feedback

1. Remember | 1 | Toddy history good, systemic exam missing, PICCLE incomplete

2. Understand | 1 | Pain pattern described, toddy / Pallor / morning stiffness not explained

3. Apply | 1 | OA + Sciatica stated, no investigations / management

4. Analyze | 1 | Two diagnoses listed, alcohol neuropathy not analyzed

5. Evaluate | 0 | No justification, toddy + tingling missed

6. Create | 0 | No original product

**Total** | **4 / 12** | **Needs Support - Developing**

*Overall CBME Feedback for Roll 21 - Progression:*

- *This portfolio = 4 / 12* - First case for Roll 21

- *Strength:* You captured the two most important clues others miss - Occupation Housewife + Addictions Toddy (2 glasses / day). That is excellent history-taking. And morning decreased movements is a key detail.

- *Critical learning from this case:* Toddy + Tingling + Pallor = think alcoholic neuropathy / B12 deficiency, not just sciatica. Sciatica needs back pain, radiation down leg, SLR test - none of those are recorded. Do not label sciatic nerve compression without neuro exam. And morning stiffness duration in minutes separates OA (<30 min) from RA (>1 hour) - always ask "how many minutes?" Also, systemic examination is missing - you cannot have a complete case without CVS / RS / CNS / P/A.

2023 Roll no 34 CBME competence based assessment of a single patient portfolio 70M SOB swelling of lower limbs

 

2/11/2026

Here is the 6-point CBME evaluation for *2023 Batch - Roll No. 34* - Portfolio: *70M Retired Auto Driver, Swelling Both Lower Limbs, SOB, Weakness, Loss of Appetite - CKD Stage V*

Based on the anonymized text you pasted. Score 0-2 per level. Total /12.

### 1. Remember - Knowledge Recall

*Evidence in portfolio:*

- Department - General Medicine, Demographics with age / sex, Occupation - Retired (Auto driver), chief complaints, HOPI, past history - HTN 4 yrs on Amlodipine 40 mg, DM since 4 yrs, Asthma, family history, personal history - Appetite Decreased, Diet Mixed, Sleep Disturbed, Bowel & Bladder Regular, Addictions - Alcohol, smoking stopped since 2 weeks, general examination, vitals - with SpO2 + Weight 62 kg included, PICCLE - full form written - Pallor Present, Icterus Absent, Clubbing Absent, Cyanosis Absent, Lymphadenopathy Absent, Edema Present, systemic examination - CVS, CNS, RS, P/A recorded, Investigations - [As written - not listed], Provisional Diagnosis - Chronic KD - Stage V due to HTN.

- Good details: Swelling both lower limbs gradual, decreased urine output, generalized weakness, loss of appetite 1 month, SOB. Negatives - No fever, burning micturition. H/O knee pain due to past trauma.

- Gaps: *Amlodipine 40 mg* - dose error, Amlodipine is 5 mg / 10 mg, not 40 mg - likely confusion with Telmisartan 40 mg. *P/A - Soft, tender, NT* - contradictory, tender + Non-Tender cannot be both. No JVP, no lung crepitations, no urine output quantity. No dialysis history. No DM medication. Investigations not listed.

*Score: 2 / 2*

- Competency met: Best documentation in Roll 34 so far - occupation, weight, full PICCLE, smoking / alcohol cessation timing.

- *Next target:* Fix drug dose - Amlodipine 40 mg is wrong. Fix P/A - tender or NT, pick one. Always list investigations with values.

### 2. Understand - Comprehension

*Evidence in portfolio:*

- Swelling + SOB + weakness + loss of appetite linked as CKD Stage V due to HTN.

- But no explanation in own words of why CKD Stage V causes swelling, SOB, weakness, loss of appetite, decreased urine.

- No explanation of Pallor + Edema - anemia + fluid overload - not explained.

- No explanation of why HTN causes CKD Stage V, and DM also present - which cause is primary?

*Score: 1 / 2*

- Partial comprehension.

- *Next target:* Explain: CKD Stage V -> kidney failure -> fluid overload -> edema + SOB, decreased urine, uremia -> loss of appetite, weakness, nausea. Explain: CKD -> anemia -> Pallor, weakness, easy fatigability, SOB. Explain: HTN 4 yrs + DM 4 yrs both cause CKD - need to explain which is more likely cause, or both together. Explain: Amlodipine also causes pedal edema - need to separate CKD edema vs drug edema.

### 3. Apply - Application to Patient Care

*Evidence in portfolio:*

- Provisional diagnosis given as Chronic KD - Stage V due to HTN.

- No investigation plan, no management plan. Investigations - "not listed on this page" - so cannot apply.

- No application of SOB + edema to care - no Chest X-ray, no Echo, no dialysis plan.

- No application of alcohol / smoking stopped 2 weeks to care.

*Score: 1 / 2*

- Partial application. Diagnosis stated, but Stage V not applied to care.

- *Next target:* Add: CBC - Pallor, RFT - Urea, Creatinine, eGFR - to prove Stage V, Electrolytes, ABG, Urine routine, Calcium, Phosphate, PTH, Vitamin D, HbA1c - DM, ECG, Chest X-ray, USG KUB, Echo. Add management - fluid / salt restriction, dialysis - is he on dialysis? If Stage V, need nephrology, dialysis planning, treat anemia, BP control, review Amlodipine dose, avoid nephrotoxins, diet - low salt / potassium, alcohol / smoking cessation counseling. Add detailed RS exam - JVP, crepitations, effusion.

### 4. Analyze - Differentiation & Interpretation

*Evidence in portfolio:*

- No formal differential diagnosis listed, but cause given as HTN.

- No analysis of alternative causes: CKD due to HTN vs DM vs Both vs Obstructive.

- No analysis of swelling + SOB - CKD vs Cardiac failure vs Liver vs Drug.

- No analysis of decreased urine - CKD vs dehydration vs obstruction.

*Score: 1 / 2*

- Partial analysis - implicit, not explicit.

- *Next target:* Add differential table: CKD Stage V due to HTN - supports HTN 4 yrs, swelling, decreased urine, weakness, Pallor, Edema, loss of appetite. CKD due to DM - supports DM 4 yrs, same symptoms; against - DM only 4 yrs, short for Stage V, need HbA1c, retinopathy. Cardiac failure - supports swelling, SOB, weakness, HTN, DM, age 70M; against - no chest pain, no murmurs, need Echo. Liver disease - supports swelling, weakness, loss of appetite, alcohol history; against - no icterus, no ascites mentioned. Drug edema - Amlodipine - supports swelling; against - SOB + decreased urine not explained. Must analyze: HTN vs DM - which caused Stage V?

### 5. Evaluate - Judgment & Reflection

*Evidence in portfolio:*

- No justification for Stage V - no eGFR, no creatinine given, yet Stage V stated.

- No justification for HTN as cause, when DM also present.

- No judgment on urgency - SOB + edema + decreased urine in 70M = need urgent RFT, electrolytes, ABG.

- No reflection, no self-assessment.

*Score: 0 / 2*

- Not met.

- *Next target:* Add: Can I label Stage V without eGFR / creatinine? What is the risk if I miss cardiac failure / pulmonary edema in a 70M with SOB + edema? What would I do differently - do RFT, ECG, Chest X-ray, check JVP, ask about dialysis, orthopnea, PND, chest pain? Reflection on CKD Stage V in retired auto driver - impact on family, dialysis burden, diet, work.

### 6. Create - Synthesis & New Learning Product

*Evidence in portfolio:*

- No original product - no algorithm, concept map, patient education material.

*Score: 0 / 2*

- Not met.

- *Next target:* Create 1-page algorithm: Swelling + SOB + Decreased Urine in Older Male -> CKD vs Cardiac vs Liver -> Investigations -> Management, OR patient education sheet for CKD Stage V - fluid, salt, diet, dialysis, red flags.

### Summary Sheet - Roll No. 34 - 2023 Batch

Bloom Level | Score /2 | Key Feedback

1. Remember | 2 | Best documentation in Roll 34, weight + full PICCLE

2. Understand | 1 | CKD linked, Stage V + Pallor + Edema not explained

3. Apply | 1 | CKD Stage V stated, no investigations / dialysis plan

4. Analyze | 1 | HTN as cause stated, DM vs HTN not analyzed

5. Evaluate | 0 | No eGFR to prove Stage V, no urgency

6. Create | 0 | No original product

**Total** | **5 / 12** | **Needs Support - Developing**

*Overall CBME Feedback for Roll 34 - Progression:*

- 60F knee + back pain / OA = 4/12, 55F knee + neck pain / Metabolic OA - duplicate = 4/12, 54F farmer knee + neck pain / OA = 4/12, 55F farmer knee pain / Metabolic OA + DM = 4/12, *This portfolio = 5/12*

- *Progress improving:* First 5/12 in Roll 34. Best PICCLE so far - you wrote Pallor Present, Icterus Absent, etc. in full, not just P/I/C/C/L/E. And you recorded Weight 62 kg - first weight in Roll 34.

- *Critical learning from this case:* Two drug errors to fix. Amlodipine 40 mg does not exist - Amlodipine is 5 mg / 10 mg, Telmisartan is 40 mg. And P/A - Soft, tender, NT - tender and Non-Tender cannot both be true. Also, you cannot label CKD Stage V without eGFR / creatinine. Stage V = eGFR <15. Without numbers, it is just CKD. And with DM + HTN both 4 years, you must analyze which caused CKD - do not pick HTN without justification.

2023 Roll no 34 CBME competence based assessment of a single patient portfolio 55F knee pain 1 yr

 

3/11/2026

Here is the 6-point CBME evaluation for *2023 Batch - Roll No. 34* - Portfolio: *55F Farmer (at present not working), Knee Pain - 1 Year, DM - 2 Years*

Based on the anonymized text you pasted. Score 0-2 per level. Total /12.

### 1. Remember - Knowledge Recall

*Evidence in portfolio:*

- Department - General Medicine, Demographics with age / sex, Occupation - Farmer (at present not working), chief complaints, HOPI, past history - H/O DM 2 yrs, N/K/C/O Asthma, TB, Epilepsy, HTN, family history, personal history - Diet Mixed, Appetite Normal, Sleep Regular, Bowel & Bladder Normal, Regular, No Addictions, general examination, vitals - with SpO2 included, PICCLE, systemic examination - CVS, RS, CNS, P/A recorded, Investigations - CBP, HbA1c listed.

- Good details: Pain in both knee joints, present 1 yr, aggravated during activity & relieved by rest. DM history captured.

- Gaps: *Timeline gap:* "Apparently normal 2 yrs ago" then "pain present for past 1 yr" - what happened in the 1 year gap? No joint examination - swelling, tenderness, crepitus, deformity, ROM. No BMI / waist despite Metabolic diagnosis. No DM details - medication, control, complications. CBP, HbA1c listed but no values. No reason for "at present not working" - due to knee pain? Not explained.

*Score: 1 / 2*

- Partial recall - occupation + PICCLE + investigations listed, good improvement, but timeline gap + joint exam + DM details missing.

- *Next target:* Clarify timeline - when exactly did pain start? Always record joint examination + BMI. Always write investigation values - CBP, HbA1c numbers, not just names. Always record DM medication - metformin? insulin?

### 2. Understand - Comprehension

*Evidence in portfolio:*

- Pain pattern described - worse on activity, better on rest.

- Provisional diagnosis - Metabolic osteoarthritis syndrome.

- But no explanation in own words of why OA causes pain worse on activity, or why DM + OA together = metabolic syndrome.

- No explanation of Farmer (at present not working) - is she not working because of knee pain? Not explained.

- No explanation of Pallor (+) - anemia not explained. No explanation of DM 2 yrs - DM worsens OA?

*Score: 1 / 2*

- Partial comprehension.

- *Next target:* Explain: OA = cartilage loss -> mechanical pain, worse on activity, better on rest. Explain: DM -> inflammation + obesity + poor cartilage healing -> OA worsens, and OA reduces activity -> DM worsens - vicious cycle. Explain: Farmer not working = functional disability due to knee pain - impact on livelihood. Explain: Pallor (+) = check Hb - anemia + DM + OA together.

### 3. Apply - Application to Patient Care

*Evidence in portfolio:*

- Provisional diagnosis given as Metabolic osteoarthritis syndrome.

- Investigations listed as CBP, HbA1c - but no values, no other investigations.

- No management plan, no application of DM to care - no sugar control, no foot care.

- No application of Pallor / not working to care.

*Score: 1 / 2*

- Partial application.

- *Next target:* Add: CBP values - Hb, HbA1c value - DM control, FBS / PPBS, Lipid profile, RFT, X-ray both knees, Vitamin D, Calcium, BMI, Waist. Add management - for OA: quadriceps exercises, physiotherapy, avoid squatting / kneeling, weight management, analgesics, knee support. For DM: diet, medication adherence, foot care, HbA1c target, follow-up. For anemia: iron, diet. For work: work modification, rest, ergonomic advice. Add detailed knee examination.

### 4. Analyze - Differentiation & Interpretation

*Evidence in portfolio:*

- No formal differential diagnosis listed.

- No analysis of alternative causes: OA vs Rheumatoid arthritis vs Osteoporosis vs Diabetic joint / Charcot vs Gout.

- No analysis of knee pain + DM - is knee pain due to OA or diabetic arthropathy?

- No analysis of "at present not working" - disability assessment missing.

*Score: 1 / 2*

- Partial analysis - implicit, not explicit.

- *Next target:* Add differential table: Osteoarthritis - supports 55F, both knees, worse on activity, better on rest, farmer. Rheumatoid Arthritis - supports joint pain; against - no swelling, no small joints. Osteoporosis - supports 55F, knee pain, DM; against - no fracture. Diabetic Arthropathy / Charcot - supports DM 2 yrs, knee pain; against - no swelling, no deformity, DM only 2 yrs. Gout - supports knee pain; against - no acute attacks, bilateral. Must analyze: Is DM causing knee pain or just co-existing?

### 5. Evaluate - Judgment & Reflection

*Evidence in portfolio:*

- No justification for Metabolic osteoarthritis syndrome - no BMI, waist, lipids, BP - BP 110/80 normal, yet metabolic syndrome claimed.

- No justification for OA without X-ray / joint exam.

- No judgment on DM control - HbA1c listed but no value, so cannot judge control.

- No reflection on why farmer not working - disability impact not evaluated.

*Score: 0 / 2*

- Not met.

- *Next target:* Add: Can I label Metabolic Syndrome when BP is 110/80 and no BMI / waist / lipids given? What is HbA1c value - is DM controlled or not? What is the risk if I miss uncontrolled DM + anemia in OA patient? What would I do differently - write HbA1c value, ask about DM medication, ask why not working - pain severity, ask about morning stiffness? Reflection on OA + DM in farmer - double burden, need holistic care.

### 6. Create - Synthesis & New Learning Product

*Evidence in portfolio:*

- No original product - no algorithm, concept map, patient education material.

*Score: 0 / 2*

- Not met.

- *Next target:* Create 1-page patient education sheet for OA + DM in Farmer - exercises, diet for DM + weight, foot care, work modification, OR algorithm: Knee Pain + DM -> OA vs Diabetic Arthropathy -> Examination -> X-ray + HbA1c -> Management.

### Summary Sheet - Roll No. 34 - 2023 Batch

Bloom Level | Score /2 | Key Feedback

1. Remember | 1 | Occupation + PICCLE + investigations listed, timeline gap

2. Understand | 1 | Pain pattern described, DM + OA link + not working not explained

3. Apply | 1 | Metabolic OA stated, CBP / HbA1c without values, no management

4. Analyze | 1 | No explicit differential, DM + knee pain not analyzed

5. Evaluate | 0 | No justification for Metabolic Syndrome, HbA1c value missing

6. Create | 0 | No original product

**Total** | **4 / 12** | **Needs Support - Developing**

*Overall CBME Feedback for Roll 34 - Progression:*

- 60F knee + back pain / OA, BP 180/90 missed = 4/12, 55F knee + neck pain / Metabolic OA - duplicate case = 4/12, 54F farmer knee + neck pain / OA = 4/12, *This portfolio = 4/12*

- *Progress steady:* Consistent 4/12 across 4 cases. Improvement - you are now consistently recording Occupation and PICCLE, and listing investigations - CBP, HbA1c.

- *Critical learning from this case:* "Metabolic osteoarthritis syndrome" is not a diagnosis until you prove it. BP is 110/80 - normal. No BMI, no waist, no lipids, no HbA1c value given. DM alone does not equal Metabolic Syndrome. And "Farmer (at present not working)" is the most important line - knee pain has stopped her work. That is disability, not just pain. Always ask why not working, how it affects income / family, and always write investigation values, not just names. CBP without Hb and HbA1c without % is not an investigation.

2023 Roll no 34 CBME competence based assessment of a single patient portfolio 54F knee pains neck pain 2yrs

 

4/11/2026

Here is the 6-point CBME evaluation for *2023 Batch - Roll No. 34* - Portfolio: *54F Farmer, Knee Pain - 2 Years, Neck Pain - 2 Years, Pain on Walking / Climbing Stairs*

Based on the anonymized text you pasted. Score 0-2 per level. Total /12.

### 1. Remember - Knowledge Recall

*Evidence in portfolio:*

- Demographics with age / sex, Occupation - Farmer - first time occupation recorded in Roll 34, chief complaints, HOPI, past history - N/K/C/O DM, HTN, Asthma, TB, Epilepsy, family history, personal history - Diet Mixed, Appetite Normal, Sleep Sound, Bowel & Bladder Regular, No Addictions, general examination, PICCLE, vitals, systemic examination - CVS, RS, CNS, P/A recorded.

- Good details: Pain in both knee joints, insidious onset, gradually progressive, difficulty in moving joint, walking and climbing stairs pain slightly increases. Neck pain 2 yrs. Negatives - No trauma, fever, wt loss.

- Gaps: *Timeline contradiction:* Chief Complaints say Knee pain x 2 yrs, but HOPI says "apparently asymptomatic 5 months back" - cannot be both. No joint examination - swelling, tenderness, crepitus, deformity, ROM. No BMI. No SpO2 recorded. No neck pain details - radiation, stiffness, numbness.

*Score: 1 / 2*

- Partial recall - occupation + PICCLE now present, good improvement, but timeline contradiction + joint exam missing.

- *Next target:* Fix timeline - was it 2 years or 5 months? Always record joint examination + neck examination + BMI. Always record SpO2.

### 2. Understand - Comprehension

*Evidence in portfolio:*

- Pain pattern described - insidious, progressive, worse on walking / climbing stairs, difficulty moving.

- Provisional diagnosis - Osteoarthritis given.

- But no explanation in own words of why OA causes pain worse on walking / climbing stairs, difficulty moving.

- No explanation of Farmer occupation - squatting, kneeling, heavy work worsens knee OA - not explained.

- No explanation of Pallor (+) - anemia not explained.

- No explanation of neck pain 2 yrs + knee pain 2 yrs together - generalized OA?

*Score: 1 / 2*

- Partial comprehension.

- *Next target:* Explain: OA = cartilage loss -> pain on weight-bearing, worse on walking / climbing stairs, stiffness, difficulty moving. Explain: Farmer - squatting, kneeling, lifting, walking on uneven ground -> increased knee load -> OA worsens. Explain: Neck pain 2 yrs + knee pain 2 yrs = generalized OA / cervical spondylosis. Explain: Pallor (+) = check Hb - anemia worsens fatigue / pain.

### 3. Apply - Application to Patient Care

*Evidence in portfolio:*

- Provisional diagnosis given as Osteoarthritis.

- No investigation plan, no management plan.

- No application of Farmer occupation to care - no work modification advice.

- No application of Pallor (+) to care.

*Score: 1 / 2*

- Partial application.

- *Next target:* Add: X-ray both knees + cervical spine, CBC - Pallor, Hb, Vitamin D, Calcium, RFT, ESR / CRP, BMI. Add management - for OA in farmer: avoid squatting / kneeling, use stool / chair, quadriceps + neck exercises, physiotherapy, weight management, analgesics, knee support, work modification - avoid heavy lifting, take breaks. For anemia: iron, diet. Follow-up. Add detailed knee + neck examination.

### 4. Analyze - Differentiation & Interpretation

*Evidence in portfolio:*

- No formal differential diagnosis listed.

- No analysis of alternative causes: OA vs Rheumatoid arthritis vs Osteoporosis vs Cervical spondylosis vs Fibromyalgia.

- No analysis of knee + neck pain together - OA generalized vs separate causes.

- No analysis of timeline contradiction - 2 yrs vs 5 months.

*Score: 1 / 2*

- Partial analysis - implicit, not explicit.

- *Next target:* Add differential table: Osteoarthritis - supports 54F, both knees, insidious, progressive, worse on walking / climbing stairs, difficulty moving, neck pain 2 yrs, farmer occupation. Rheumatoid Arthritis - supports joint pain, difficulty moving; against - no swelling / redness, no small joints, no morning stiffness. Osteoporosis - supports 54F, knee + neck pain; against - no fracture, no height loss. Cervical Spondylosis - supports neck pain 2 yrs, age 54F; against - no radiation, no numbness mentioned. Must analyze: Is neck pain due to cervical spondylosis or generalized OA? Is timeline 2 yrs or 5 months?

### 5. Evaluate - Judgment & Reflection

*Evidence in portfolio:*

- No justification for OA without X-ray / joint exam.

- No judgment on timeline contradiction - not noticed.

- No judgment on occupation impact - farmer work is the main risk factor, not evaluated.

- No reflection, no self-assessment.

*Score: 0 / 2*

- Not met.

- *Next target:* Add: Can I label OA without X-ray? What is the risk if I miss osteoporosis / RA in a 54F farmer? What would I do differently - clarify timeline with patient, ask about squatting / kneeling hours, ask about morning stiffness duration, check BMI, do joint exam? Reflection on chronic pain in farmer - impact on livelihood, walking, climbing, work capacity.

### 6. Create - Synthesis & New Learning Product

*Evidence in portfolio:*

- No original product - no algorithm, concept map, patient education material.

*Score: 0 / 2*

- Not met.

- *Next target:* Create 1-page patient education sheet for OA in Farmer - work modification, avoid squatting / kneeling, exercises, posture, OR algorithm: Knee + Neck Pain in Farmer -> OA vs Osteoporosis vs RA -> Examination -> X-ray + Work History -> Management.

### Summary Sheet - Roll No. 34 - 2023 Batch

Bloom Level | Score /2 | Key Feedback

1. Remember | 1 | Occupation + PICCLE present, timeline contradiction

2. Understand | 1 | Pain on stairs described, farmer work + Pallor not explained

3. Apply | 1 | OA stated, no investigations / work advice / management

4. Analyze | 1 | No explicit differential, knee + neck together not analyzed

5. Evaluate | 0 | No justification, timeline error missed

6. Create | 0 | No original product

**Total** | **4 / 12** | **Needs Support - Developing**

*Overall CBME Feedback for Roll 34 - Progression:*

- 60F knee + back pain / OA, BP 180/90 missed = 4/12, 55F knee + neck pain / Metabolic OA - duplicate case = 4/12, *This portfolio = 4/12*

- *Progress steady:* Consistent 4/12. Improvement - you finally recorded Occupation - Farmer - and PICCLE with Pallor (+) in this case. That is the first complete PICCLE in Roll 34.

- *Critical learning from this case:* Occupation is the diagnosis here. Farmer + knee pain worse on walking / climbing stairs + difficulty moving = mechanical OA worsened by squatting / kneeling / heavy work. Always link occupation to pain. And fix the timeline - Chief Complaints say 2 years, HOPI says asymptomatic 5 months back. Both cannot be true. One line error makes the whole history unreliable. Also Pallor (+) again - check Hb in every OA case, anemia is missed in Roll 34 so far.