27/10/2026
Here is the 6-point CBME evaluation for *2023 Batch - Roll No. 12* - Portfolio: *CASE 4 - 49M, Worker, Decreased Urine Output - 2 Years, SOB on Walking - 2 Years, Swelling Both Feet - 2 Years, CKD - 2 Years, Haemodialysis - 18 Months, HTN - Losartan + Furosemide + Amlodipine, Urine 200 ml / Day, BP 160/90, Pallor +, Edema +*
Based on the anonymized text you pasted. Score 0-2 per level. Total /12.
### 1. Remember - Knowledge Recall
*Evidence in portfolio:*
- Demographics - Age / Sex: 49 years / Male, Occupation: Worker, chief complaints - Decreased urine output since 2 years, SOB since 2 years, on walking, Swelling of both feet since 2 years, HOPI - Asymptomatic 2 years ago, then diagnosed with CKD, 2 years ago developed bilateral pedal edema (pitting edema), Initially ankles, slowly progressed to entire leg, No itching, Swelling associated with pain, More pain while walking and has difficulty in lying down, Breathlessness gradually progressive, 2 years ago noticed oliguria, No dysuria, 2 years ago diagnosed with CKD on blood test, Since then taking hemodialysis, HOPI Continued - Pedal edema 2 years ago, treated by Furosemide and fluid restriction, Daily monitoring of weight, urine output, BP, kidney function and electrolyte, No productive cough, chest pain, Asymptomatic since 2 years, then diagnosed with HTN and on medication, Past History - Known case HTN 2 years: Losartan, Furosemide, Amlodipine, CKD 2 years ago: Haemodialysis since 18 months, No TB, Asthma, COPD, No major surgeries, Personal History - Appetite Decreased, Diet Mixed, Sleep Disturbed, Bowel Regular, Bladder Oliguria 200 ml/day - 2-3 episodes per day, Addictions No, Family History - No significant, General Examination - PICCLE: P - Pallor Present (+), I - Icterus Absent, C - Cyanosis Absent, C - Clubbing Absent, L - Lymphadenopathy Absent, E - Edema Present (+) - Pedal Edema, pitting edema, Vitals - BP 160/90 mmHg, RR 22/min, Temp Afebrile, SpO2 98% on Room Air, AV Fistula Examination - On Right Side, Inspection: Surgical scar on both hand and chest, No prominent vein, No redness, ulceration, discharge, Palpation: Thrill continuous, Fistula not tender / warm.
- Good details: Timeline - all 2 years ago - CKD, edema, SOB, oliguria - together, dialysis 18 months, edema pattern - ankles -> entire leg, pitting, associated with pain, pain on walking, difficulty lying down, breathlessness - gradually progressive, on walking, oliguria - 200 ml/day, 2-3 episodes/day, no dysuria, no itching, treatment - Furosemide + fluid restriction, daily monitoring - weight, urine, BP, kidney function, electrolyte, drugs - Losartan, Furosemide, Amlodipine - complete, PICCLE - Pallor +, Edema + - pitting - complete, vitals - BP, RR, Temp, SpO2 - complete except Pulse, AV fistula - Right Side, Inspection + Palpation - scar hand + chest, no redness / ulcer / discharge, thrill continuous, not tender / warm.
- Gaps: *Pulse - Not recorded.* *No Systemic Examination - CVS, CNS, RS, P/A - missing.* *No AV Fistula Auscultation - Bruit - missing.* *No Investigations - RFT, CBC, Hb, Electrolytes, eGFR.* *No Last dialysis date, No Dry weight, No Dialysis frequency - times/week?* *No Provisional Diagnosis - CKD - not written explicitly.* *Scar "on both hand and chest"* - chest scar - for what? - not explained - dialysis catheter? *"Difficulty in lying down"* - orthopnoea? - not clarified.
*Score: 1 / 2*
- Partial recall - timeline, drugs, PICCLE, fistula exam good, but Pulse, systemic exam, investigations, diagnosis missing.
- *Next target:* Always record Pulse - in CKD + SOB + HTN, Pulse is essential. Always do Systemic Examination - CVS, CNS, RS, P/A - especially RS - crepitations? - in SOB + edema. Always add AV Fistula Auscultation - Bruit + / -. Always record Investigations - RFT - urea, creatinine, eGFR, CBC - Hb - Pallor + needs Hb, Electrolytes - K, Ca, Phosphate, Chest X-ray. Always record Dialysis - times/week, last dialysis, dry weight. Always write Provisional Diagnosis. Always clarify - Scar on chest = temporary dialysis catheter? Difficulty lying down = orthopnoea / PND?
### 2. Understand - Comprehension
*Evidence in portfolio:*
- Edema ankles -> entire leg, pitting, pain on walking, difficulty lying down, SOB on walking, gradually progressive, oliguria 200 ml/day - described.
- But no explanation in own words of why CKD causes edema, SOB, oliguria, pallor, difficulty lying down.
- No explanation of AV fistula - why thrill = working, why chest scar - not explained. No explanation of BP 160/90, Furosemide + fluid restriction - not explained.
*Score: 1 / 2*
- Partial comprehension.
- *Next target:* Explain: CKD -> kidneys cannot clear water / salt / urea -> fluid overload -> bilateral pedal edema ankles -> entire leg, pitting, SOB on walking, gradually progressive. Explain: Difficulty lying down = orthopnoea - fluid in lungs when lying flat. Explain: Oliguria 200 ml/day, 2-3 episodes/day = kidneys failing, dialysis needed. Explain: Pallor + = anaemia - kidney does not make erythropoietin. Explain: Furosemide + fluid restriction = remove fluid, reduce edema / SOB. Explain: Daily monitoring - weight, urine, BP, kidney function, electrolyte = check fluid overload, K. Explain: AV Fistula - Right Side - Radial / Cephalic - Thrill continuous = fistula working, Not tender / warm = no infection. Explain: BP 160/90 = uncontrolled HTN due to fluid overload + kidney failure, Losartan + Amlodipine for HTN.
### 3. Apply - Application to Patient Care
*Evidence in portfolio:*
- Treatment - Furosemide + fluid restriction, daily monitoring - weight, urine, BP, kidney function, electrolyte - given in HOPI.
- AV Fistula Examination done.
- But no student plan - no investigation plan, no management plan written by student - only what others did.
- No application of BP 160/90, SOB on walking, difficulty lying down to care - no urgent dialysis, no lung check.
*Score: 1 / 2*
- Partial application - Furosemide + monitoring applied, but no care plan.
- *Next target:* Add: CBC - Hb - Pallor +, RFT - urea, creatinine, eGFR, Electrolytes - K, Na, Ca, Phosphate, ABG, ECG, Chest X-ray - pulmonary edema, USG abdomen - kidney size. Add management - Continue dialysis - clarify times/week, do not miss, fluid restriction, low salt, daily weight, check BP daily, check fistula daily - thrill / bruit, keep clean, no BP / blood draw on right arm, treat anaemia - iron, erythropoietin, treat HTN - Losartan + Amlodipine - check K, creatinine, monitor SOB, edema, urine, sleep, appetite, refer - Nephrology. Add: If SOB + difficulty lying down + BP 160/90 - urgent - check lungs for crepitations, check SpO2, urgent dialysis.
### 4. Analyze - Differentiation & Interpretation
*Evidence in portfolio:*
- No provisional diagnosis, no differential list.
- No analysis of alternative causes: CKD vs Heart failure vs Liver failure vs Nephrotic syndrome.
- No analysis of SOB causes: Fluid overload vs Heart failure vs Anaemia vs Pulmonary edema.
- No analysis of edema with pain - CKD vs Cellulitis vs DVT - pain + swelling + not tender / warm fistula - not differentiated.
*Score: 1 / 2*
- Partial analysis - CKD pattern recognized, but not differentiated.
- *Next target:* Add differential table: CKD Stage 5 on Dialysis - supports 49M, CKD 2 years, dialysis 18 months, edema ankles -> entire leg, pitting, SOB on walking, oliguria 200 ml/day, Pallor +, Edema +, BP 160/90, Furosemide + fluid restriction; against - no RFT, eGFR, USG kidney given, cause of CKD unknown, dialysis frequency unknown. Heart Failure - supports SOB on walking, difficulty lying down, edema, HTN; against - no chest pain, productive cough, no CVS / RS exam. Liver Failure - supports edema, appetite ↓; against - no jaundice, ascites, Icterus absent, no itching. Nephrotic Syndrome - supports edema, HTN; against - no frothy urine, no urine protein mentioned. Cellulitis / DVT - supports edema + pain on walking; against - no redness, warmth, fever, Temp Afebrile, edema bilateral, not unilateral. Must analyze: Is difficulty lying down orthopnoea from fluid overload or heart failure? Is edema pain due to fluid or DVT?
### 5. Evaluate - Judgment & Reflection
*Evidence in portfolio:*
- Negatives - No itching, No dysuria, No productive cough, chest pain - show judgment - you ruled out liver / UTI / lung causes.
- AV Fistula Examination - Thrill continuous, Not tender / warm, No redness / ulcer / discharge - shows judgment - fistula working, not infected.
- Daily monitoring - weight, urine, BP, kidney function, electrolyte - shows judgment - you know what to monitor in CKD.
- But no judgment on BP 160/90, SOB on walking, difficulty lying down - not flagged as urgent.
- No reflection.
*Score: 1 / 2*
- Partial evaluation - fistula + negatives + monitoring show judgment, but vitals / SOB judgment missing.
- *Next target:* Add: Can I label CKD Stage 5 without eGFR / USG? What is most urgent - SOB on walking + difficulty lying down + BP 160/90 + edema entire leg - is he in fluid overload / pulmonary edema? What is the risk if I miss pulmonary edema / hyperkalaemia / severe anaemia in a 49M on dialysis with SOB + edema? What would I do differently - check Pulse, check lungs for crepitations, check weight gain, check last dialysis, check fistula bruit, ask about orthopnoea / PND, missed dialysis? Reflection on 49M worker - 2 years CKD, 18 months dialysis - impact on work, family, daily wages, diet - salt / fluid restriction, dialysis burden, anaemia - weakness, walking difficulty?
### 6. Create - Synthesis & New Learning Product
*Evidence in portfolio:*
- No original product - no algorithm, concept map, patient education material, Socratic questions.
*Score: 0 / 2*
- Not met.
- *Next target:* Create 1-page algorithm: CKD on Dialysis + SOB on Walking + Difficulty Lying Down + Edema Entire Leg -> Fluid Overload vs Heart Failure -> Examination -> RFT + Chest X-ray + AV Fistula Check -> Urgent Dialysis, OR patient education sheet for CKD on Dialysis - Daily Monitoring - weight, urine, BP, fluid / salt, AV Fistula Care, when to go to hospital - breathlessness, swelling, urine ↓, OR Socratic questions like Case 1.
### Summary Sheet - Roll No. 12 - 2023 Batch
Bloom Level | Score /2 | Key Feedback
1. Remember | 1 | Timeline + drugs + PICCLE + fistula good, Pulse / systemic / investigations missing
2. Understand | 1 | Edema + SOB + oliguria described, CKD mechanism not explained
3. Apply | 1 | Furosemide + monitoring applied, no own RFT / management plan
4. Analyze | 1 | CKD pattern recognized, no differential table
5. Evaluate | 1 | Fistula + negatives show judgment, BP 160/90 / SOB missed
6. Create | 0 | No original product
**Total** | **5 / 12** | **Developing - Competent**
*Overall CBME Feedback for Roll 12 - Progression:*
- CASE 1 CKD 49F = 7/12, CASE 2 CKD 26M = 6/12, CASE 3 Headache 54F = 5/12, *This portfolio = 5/12*
- *Progress down, but drugs + monitoring are good:* Losartan + Furosemide + Amlodipine - complete, plus Furosemide + fluid restriction + Daily monitoring - weight, urine output, BP, kidney function, electrolyte - that is exactly what CKD on dialysis needs, and you captured it. Edema - ankles -> entire leg, pitting, associated with pain, pain on walking, difficulty lying down - is a detailed fluid overload story. AV Fistula - Right Side, Thrill continuous, Not tender / warm, No redness / ulcer / discharge - is again good.
- *Critical learning from this case:* You have no Pulse, no Systemic Examination, no Bruit - in CKD + SOB + edema, Pulse + RS - crepitations? - are not optional. And "Difficulty in lying down" is orthopnoea - a red flag for pulmonary edema - you must flag it, not just list it. Add Pulse + Systemic Exam + Bruit + RFT + Hb + last dialysis + dialysis frequency, and this case becomes 8-9/12.
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