27/10/2026
Here is the 6-point CBME evaluation for *2023 Batch - Roll No. 14* - Portfolio: *CASE 1 - CKD STAGE 5 ON MAINTENANCE - 26M, Doing Business, Fever 3 Years Ago, Swelling Feet, Breathlessness, Dialysis 3 Days / Week*
Based on the anonymized text you pasted. Score 0-2 per level. Total /12.
### 1. Remember - Knowledge Recall
*Evidence in portfolio:*
- Case History - Age / Sex: 26 years / Male, Occupation: Doing business, chief complaints - Fever 3 years ago, Swelling in feet 3 years ago, HOPI - Overweight 82 kg, assumed breathlessness 4 years ago, Breathlessness increased climbing stairs, decreased sitting 5-10 mins, Then 3 years ago fever 3 days, decreased with Paracetamol during night, After fever subsided, swelling feet, yellowish discoloration of feet and weight loss, Assumed it was jaundice, CBC low hemoglobin, Personal History - Diet Mixed, advised to avoid red meat, Likes mutton, cucumber, mango, papaya, fruit, Appetite Adequate, Sleep Disturbed while lying down, fullness around 2-3 am, wakes in between, Addictions Nil, Used to consume outside food frequently before, Family History - No similar complaints, H/o HTN in family, DM mother 2 yrs, Father has..., General Examination - Pt in C/C/C, well oriented to TPP, PICCLE - Pallor -, Icterus -, Cyanosis -, Clubbing -, Lymphadenopathy -, Edema -, Vitals - Pulse 110/min, BP 140/120 mmHg, SpO2 95%, Systemic Examination - CVS S1S2 +, No murmur, CNS NFD, RS NVBS, Abdomen Soft, NT, Investigations - RBS 59 mg/dl, RFT Urea 122 mg/dl, Creatinine 8.9 mg/dl, Provisional Diagnosis: CKD Stage 5, Past History - No H/o Epilepsy / Asthma / TB, General Examination - Conscious, well oriented, Pallor Absent, Icterus Absent, Cyanosis Absent, Clubbing Absent, Lymphadenopathy Absent, Edema Absent, Vitals - Pulse 110 bpm, BP 140/120 mmHg, SpO2 95%, Systemic Examination - CVS S1S2, No murmur, CNS NFD, RS NVBS, Abdomen Soft, NT, Investigations - RBS 59, RFT Urea 122, Creatinine 8.9, Hb 6.5 gm, Provisional Diagnosis - CKD, History Continued - Serum Creatinine 13.4, Nephrologist advised dialysis, Asked to limit water and salt, Developed breathlessness 1 year ago, not associated with chest pain nor swelling feet, Prescribed by cardiologist Sildenafil, Isosorbide dinitrate 20 mg, H/o Anuria since undergoing dialysis, H/o Breathlessness while lying down, Undergoes dialysis 3 days - alternate days - in a week, H/o Abdomen swelling when gap for 2 days - Saturdays & Sundays, Past History - No similar complaints 4 years ago, Known case of HTN since dialysis started, No H/o DM / Asthma / Epilepsy, Gets fever rarely.
- Good details: Long timeline - breathlessness 4 years ago, fever 3 years ago, swelling 3 years ago, dialysis now - excellent chronology, weight 82 kg, breathlessness on climbing stairs, relieved sitting 5-10 mins, orthopnoea - breathlessness lying down, sleep disturbed 2-3 am, fullness, anuria on dialysis, abdomen swelling on 2-day gap - fluid overload pattern, dialysis 3 days alternate days, creatinine 8.9 -> 13.4, urea 122, Hb 6.5, RBS 59, drugs - Sildenafil, Isosorbide dinitrate 20 mg, occupation, diet likes, family history.
- Gaps: *Duplication* - General Examination, Vitals, Systemic Examination, Investigations repeated twice - same values - need to clean. *Contradictions not clarified* - PICCLE Edema Absent but history swelling feet + abdomen swelling on gap, PICCLE Pallor Absent but Hb 6.5 gm - severe anaemia, but Pallor Absent? *BP 140/120 mmHg* - diastolic 120 - severe, not flagged. *RBS 59 mg/dl* - low, not flagged. *RR - Not recorded.* *Temp - Not recorded.* *No dialysis details* - fistula / catheter, dry weight, last dialysis, urine output. *No USG kidney, no eGFR, no electrolytes, no calcium / phosphate / PTH.*
*Score: 2 / 2*
- Full recall - timeline, dialysis, investigations, family, diet - all present, despite duplication.
- *Next target:* Remove duplication - write General Examination / Vitals / Systemic Examination once. Always reconcile contradictions before submitting - if Hb 6.5, Pallor must be Present, if swelling history, Edema must be checked now - Present / Absent with explanation. Always record RR, Temp. Always flag abnormal vitals / labs - BP 140/120 - diastolic crisis, RBS 59 - hypoglycaemia, Pulse 110 - tachycardia, Hb 6.5 - severe anaemia. Always record dialysis access - fistula / catheter, dry weight, last session.
### 2. Understand - Comprehension
*Evidence in portfolio:*
- Breathlessness pattern - on climbing stairs, relieved sitting, breathlessness lying down, sleep disturbed 2-3 am, fullness - described.
- Swelling pattern - feet swelling after fever, abdomen swelling on 2-day dialysis gap - described.
- But no explanation in own words of why CKD causes breathlessness, swelling, anaemia, anuria.
- No explanation of why creatinine 8.9 -> 13.4 means worsening, why Hb 6.5, urea 122 matter.
- No explanation of Sildenafil + Isosorbide dinitrate - why cardiologist gave them - pulmonary hypertension / heart failure? - not explained.
*Score: 1 / 2*
- Partial comprehension.
- *Next target:* Explain: CKD Stage 5 = eGFR <15, kidneys cannot clear urea / creatinine / water -> urea 122, creatinine 8.9-13.4, anuria, swelling feet / abdomen on dialysis gap = fluid overload. Explain: Breathlessness lying down + sleep disturbed 2-3 am = orthopnoea / PND - fluid in lungs, heart failure in CKD. Explain: Hb 6.5 = anaemia - kidney does not make erythropoietin + blood loss on dialysis. Explain: BP 140/120 = HTN due to fluid overload + kidney failure. Explain: Sildenafil + Isosorbide dinitrate = for pulmonary hypertension / heart failure - common in CKD, need to check. Explain: RBS 59 = low sugar - in CKD, insulin clearance reduced, risk of hypoglycaemia.
### 3. Apply - Application to Patient Care
*Evidence in portfolio:*
- Provisional Diagnosis - CKD Stage 5 / CKD.
- Investigations given - RBS, RFT, Hb.
- History - Nephrologist advised dialysis, limit water and salt, dialysis 3 days alternate days.
- But no student plan - no investigation plan, no management plan written by student - only what others did.
- No application of BP 140/120, Pulse 110, SpO2 95%, Hb 6.5, RBS 59 to care.
*Score: 1 / 2*
- Partial application - dialysis + salt / water restriction captured, but not applied as own plan.
- *Next target:* Add: CBC, Electrolytes - K, Na, Ca, Phosphate, PTH, Vitamin D, ABG, ECG, Chest X-ray, USG abdomen - kidney size, eGFR calculation, Urine routine if any, Dialysis adequacy - Kt/V. Add management - Continue dialysis 3 days / week, do not miss, especially no 2-day gap without fluid restriction, low salt, fluid restriction - measure daily weight, treat anaemia - iron, erythropoietin, treat HTN - BP control, avoid nephrotoxins, monitor blood sugar - RBS 59 - hypoglycaemia risk, check for chest pain, breathlessness, refer - Nephrology / Cardiology. Add: Check dialysis access for infection, check for fever.
### 4. Analyze - Differentiation & Interpretation
*Evidence in portfolio:*
- Provisional Diagnosis - CKD Stage 5 - single diagnosis, no differential list.
- No analysis of alternative causes: Hypertensive nephropathy vs Diabetic nephropathy vs Chronic glomerulonephritis vs Obstructive uropathy vs Polycystic kidney.
- No analysis of breathlessness causes: Fluid overload vs Heart failure vs Anaemia vs Pulmonary hypertension.
- No analysis of swelling causes: CKD vs Heart failure vs Liver disease.
*Score: 1 / 2*
- Partial analysis - CKD Stage 5 with creatinine 13.4 + anuria + dialysis pattern recognized, but not differentiated.
- *Next target:* Add differential table: CKD Stage 5 - supports 26M, creatinine 8.9 -> 13.4, urea 122, Hb 6.5, anuria, dialysis, swelling on gap, breathlessness lying down; against - need USG kidney size, eGFR, urine protein, cause unknown. Hypertensive Nephropathy - supports HTN since dialysis, BP 140/120, family HTN; against - HTN since dialysis, not before, age 26 young. Diabetic Nephropathy - supports family DM mother; against - No DM in patient, RBS 59, no DM history. Chronic Glomerulonephritis - supports fever 3 years ago then swelling, young age; against - no urine protein / haematuria mentioned. Must analyze: Why did 26M develop CKD? What was the cause - fever 3 years ago was trigger or coincidence? Is breathlessness due to fluid overload, anaemia Hb 6.5, or heart failure?
### 5. Evaluate - Judgment & Reflection
*Evidence in portfolio:*
- No justification for CKD Stage 5 - no eGFR, no USG, no urine protein - staging based on creatinine only.
- No judgment on dangerous values - BP 140/120 diastolic 120, Pulse 110, RBS 59, Hb 6.5, SpO2 95% - none flagged as urgent.
- No judgment on Sildenafil + Isosorbide dinitrate - both lower BP, with BP 140/120 - risk? - not evaluated.
- No reflection.
*Score: 1 / 2*
- Partial evaluation - timeline + dialysis gap swelling shows judgment, but dangerous values missed.
- *Next target:* Add: Can I label CKD Stage 5 with creatinine 8.9-13.4 alone? Need eGFR, USG, duration >3 months. What is most urgent - BP 140/120, RBS 59, Hb 6.5, or breathlessness lying down? What is the risk if I miss hypertensive emergency / hypoglycaemia / severe anaemia / pulmonary edema in a 26M on dialysis? What would I do differently - check BP again, check blood sugar, check SpO2, check weight gain between dialysis, check lungs for crepitations, ask about chest pain? Reflection on 26M on dialysis - impact on business, family, daily life, 3 days / week dialysis, diet restriction - avoid red meat but likes mutton - compliance?
### 6. Create - Synthesis & New Learning Product
*Evidence in portfolio:*
- No original product - no algorithm, concept map, patient education material.
- Timeline is good, but not synthesized into a pathway.
*Score: 0 / 2*
- Not met.
- *Next target:* Create 1-page algorithm: Young Adult with Breathlessness + Swelling + High Creatinine -> CKD Stage 5 vs Heart Failure -> Examination -> RFT + eGFR + USG -> Dialysis + Fluid Restriction, OR patient education sheet for CKD on Dialysis - diet, fluid, salt, dialysis regularity, anaemia, BP control, avoid missing dialysis on weekends.
### Summary Sheet - Roll No. 14 - 2023 Batch
Bloom Level | Score /2 | Key Feedback
1. Remember | 2 | Timeline + dialysis + labs complete, duplication + contradictions
2. Understand | 1 | Breathlessness / swelling described, CKD mechanism not explained
3. Apply | 1 | Dialysis + restriction captured, no own plan
4. Analyze | 1 | CKD pattern recognized, no differential table
5. Evaluate | 1 | Dialysis gap swelling shows judgment, BP 140/120 / RBS 59 / Hb 6.5 missed
6. Create | 0 | No original product
**Total** | **6 / 12** | **Developing - Competent**
*Overall CBME Feedback for Roll 14 - Progression:*
- *This portfolio = 6 / 12* - First case for Roll 14
- *Strength:* Best timeline in this batch - breathlessness 4 years ago, fever 3 years ago, swelling 3 years ago, creatinine 8.9 -> 13.4, dialysis now, abdomen swelling on Saturday-Sunday gap. That 2-day gap swelling is a textbook fluid overload pattern, and you captured it. You also captured diet likes - mutton, cucumber, mango, papaya - and family history - HTN family, DM mother - which shows you listened to the patient.
- *Critical learning from this case:* You recorded dangerous numbers but did not flag them - BP 140/120 - diastolic 120 is hypertensive emergency range, RBS 59 is hypoglycaemia, Hb 6.5 is severe anaemia, Pulse 110 is tachycardia, SpO2 95% is low. In a CKD patient, these are not just numbers, they are red flags. And Pallor Absent with Hb 6.5, Edema Absent with swelling history - you must reconcile your examination with your labs and history before submitting. Clean duplication, flag abnormal values, add eGFR + USG to prove Stage 5, and this case becomes 8-9/12.
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