26/10/2026
Here is the 6-point CBME evaluation for *2023 Batch - Roll No. 17* - Portfolio: *CASE 4 - 46M, SOB - 1.5 Years, Pain + Swelling Legs - 1.5 Years, Decreased Urine Output - 1.5 Years, AV Fistula - 1.5 Years, Dialysis 3 Times / Week, Provisional Diagnosis: CKD*
Based on the anonymized text you pasted. Score 0-2 per level. Total /12.
### 1. Remember - Knowledge Recall
*Evidence in portfolio:*
- 46 years / Male, C/O: SOB 1.5 years, pain 1.5 years, Swelling of leg, Decreased urine output (Dysuria) 1.5 years, Appetite decreased, HOPI: Asymptomatic 2 years ago, then developed SOB on exertion, gradual onset, progressive, MMRC grade III, aggravated by exercise, relieved by rest, No chest pain, wheezing, Developed pitting edema bilateral feet and hands, gradual onset, progressively increasing, Decreased urinary frequency 4 times/day, Past History: AV fistula -> 1.5 years dialysis, 3 times/week for 4 hrs, Personal History: Diet Mixed, Appetite Decreased, Bowel Normal, Bladder Oliguria 4 times/day, Sleep Normal, AV Fistula Examination: Radial Artery - Cephalic Vein, Left forearm, Inspection - Scar +, Swelling +, No Redness, Palpation - Thrill +, Auscultation - Bruit +, Provisional Diagnosis: CKD, Age/Sex: 46/M, C/C: SOB 1.5yr, Pain & swelling legs 1.5yrs, ↓ urine output 1.5yrs, Dialysis schedule: Monday & Thursday, Follow up - Pt look dull & weak, Appetite ↓, Pedal edema (+), Last dialysis session - 26/10/26.
- Good details: Timeline - asymptomatic 2 years ago, SOB + pain + swelling + ↓ urine 1.5 years ago, dialysis 1.5 years - chronology clear, SOB pattern - on exertion, gradual, progressive, MMRC grade III, aggravated exercise, relieved rest, no chest pain / wheezing, edema - pitting, bilateral feet and hands, gradual, progressive, urine - 4 times/day, oliguria, AV Fistula Examination - best in batch - Radial Artery - Cephalic Vein, Left forearm, Inspection Scar +, Swelling +, No Redness, Palpation Thrill +, Auscultation Bruit +, dialysis - 3 times/week, 4 hrs, last dialysis 26/10/26, follow-up - dull & weak, appetite ↓, pedal edema (+).
- Gaps: *Contradictions* - "Decreased urine output (Dysuria)" - dysuria = pain on passing urine, not decreased output, "Dialysis 3 times/week" vs "Dialysis schedule: Monday & Thursday" - 2 days only, "Swelling of leg" vs "edema feet and hands". *No General Examination - PICCLE missing.* *No Vitals - BP, PR, RR, SpO2, Temp missing - critical in CKD + SOB.* *No Systemic Examination - CVS, RS, CNS, P/A missing.* *No Investigations - RFT, CBC, Electrolytes, Hb.* *No Past History - HTN, DM, cause of CKD.* *No Family History.* *No Drug History.* *Pain details* - where, type, severity? - missing.
*Score: 1 / 2*
- Partial recall - SOB + edema + AV fistula exam excellent, but vitals, systemic exam, investigations, contradictions missing.
- *Next target:* Clean contradictions before submitting - Dysuria vs Oliguria - which one? Dialysis 3 times/week vs Monday & Thursday - which one? Always record General Examination - PICCLE, Vitals - BP, PR, RR, SpO2, Temp - in CKD + SOB + edema. Always do Systemic Examination - CVS, RS - crepitations?, CNS, P/A. Always record Investigations - RFT - urea, creatinine, eGFR, CBC - Hb, Electrolytes - K, Ca, Phosphate, Chest X-ray, ECG. Always record Past History - Cause of CKD - HTN, DM, glomerulonephritis? Always record Drug History - antihypertensives, phosphate binders, erythropoietin.
### 2. Understand - Comprehension
*Evidence in portfolio:*
- SOB on exertion + pitting edema + ↓ urine + dialysis pattern described - MMRC III, SOB relieved rest, edema progressive, oliguria 4 times/day.
- But no explanation in own words of why CKD causes SOB, edema, ↓ urine, why AV fistula needs thrill / bruit.
- No explanation of MMRC III - what it means - not explained.
*Score: 1 / 2*
- Partial comprehension.
- *Next target:* Explain: CKD -> kidneys cannot clear water / urea -> fluid overload -> pitting edema feet + hands, SOB on exertion, MMRC III = SOB on walking 100m / few minutes, stops after. Explain: Oliguria 4 times/day = kidneys not making urine, waste accumulates. Explain: AV Fistula - Radial Artery to Cephalic Vein - joins artery to vein for dialysis, Thrill + = vibration felt - blood flowing, Bruit + = sound heard - fistula working, Swelling + = fistula site swelling, No Redness = no infection. Explain: Appetite ↓, dull & weak = uremia, anaemia in CKD. Explain: Last dialysis 26/10/26 - if gap, fluid overload increases - SOB + edema.
### 3. Apply - Application to Patient Care
*Evidence in portfolio:*
- Provisional Diagnosis: CKD.
- AV Fistula Examination done - Inspection, Palpation, Auscultation - applied.
- But no investigation plan, no management plan - no dialysis adequacy, no fluid restriction, no BP control.
- No application of SOB MMRC III + pedal edema + last dialysis 26/10/26 to care - no urgent check for fluid overload.
*Score: 1 / 2*
- Partial application - AV fistula exam applied, but no care plan.
- *Next target:* Add: CBC - Hb, 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 2 vs 3 times/week, do not miss, fluid restriction, low salt, daily weight, check fistula daily - thrill / bruit, keep clean, no BP / blood draw on left arm, treat anaemia - iron, erythropoietin, treat HTN - BP control, monitor SOB, edema, urine, follow-up - dull & weak + appetite ↓ - check Hb, urea. Add: If SOB worsens, pedal edema increases, last dialysis gap - urgent dialysis, check lungs for crepitations.
### 4. Analyze - Differentiation & Interpretation
*Evidence in portfolio:*
- Provisional Diagnosis: CKD - single 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 AV fistula - Thrill + / Bruit + = working, Swelling + = ? - not interpreted.
*Score: 1 / 2*
- Partial analysis - CKD + dialysis + AV fistula pattern recognized, but not differentiated.
- *Next target:* Add differential table: CKD Stage 5 on Dialysis - supports 46M, SOB 1.5 years, edema feet + hands, oliguria 4 times/day, dialysis 1.5 years, AV fistula, pedal edema, dull & weak; against - no RFT, eGFR, USG kidney given, cause of CKD unknown. Heart Failure - supports SOB on exertion, MMRC III, pitting edema, relieved rest; against - no chest pain, wheezing, no orthopnoea / PND mentioned, no CVS / RS exam. Liver Failure - supports edema, appetite ↓; against - no jaundice, ascites, Icterus not recorded. Nephrotic Syndrome - supports edema feet + hands, appetite ↓; against - no frothy urine, no RFT / urine protein mentioned. Must analyze: Is SOB due to fluid overload from missed dialysis, anaemia, or heart failure? Is AV fistula working - Thrill + / Bruit + = yes, Swelling + = normal post-fistula or infection / aneurysm? No Redness = no infection - good.
### 5. Evaluate - Judgment & Reflection
*Evidence in portfolio:*
- AV Fistula Examination - Thrill +, Bruit +, No Redness - shows judgment - you checked if fistula is working and not infected.
- Follow-up - Pt dull & weak, appetite ↓, pedal edema (+), last dialysis 26/10/26 - shows monitoring.
- But no judgment on contradictions - 3 times/week vs Monday & Thursday - not evaluated.
- No judgment on MMRC III + pedal edema + SOB - severity - not graded.
- No reflection.
*Score: 1 / 2*
- Partial evaluation - AV fistula exam shows judgment, but dialysis schedule / severity judgment missing.
- *Next target:* Add: Can I label CKD without RFT / eGFR / USG? What is most urgent - SOB MMRC III + pedal edema + last dialysis 26/10/26 - is he in fluid overload? What is the risk if I miss pulmonary edema / hyperkalaemia / severe anaemia in a 46M on dialysis with SOB + edema? What would I do differently - check BP, SpO2, RR, lungs for crepitations, check weight gain between dialysis, check fistula thrill / bruit daily, clarify dialysis schedule - 2 vs 3 times/week? Reflection on 46M on dialysis 1.5 years - impact on work, family, diet, fluid restriction, 4 hrs x 3 times/week dialysis burden.
### 6. Create - Synthesis & New Learning Product
*Evidence in portfolio:*
- No original product - no algorithm, concept map, patient education material.
- AV Fistula Examination table is good data, but not a full product.
*Score: 0 / 2*
- Not met.
- *Next target:* Create 1-page algorithm: SOB + Edema + ↓ Urine on Dialysis -> Fluid Overload vs Heart Failure -> Examination -> RFT + Chest X-ray + AV Fistula Check -> Dialysis, OR patient education sheet for CKD on Dialysis - AV Fistula Care - check thrill / bruit daily, keep clean, no BP / blood draw on fistula arm, fluid / salt restriction, dialysis regularity, warning signs - SOB, edema, fever, fistula pain / redness.
### Summary Sheet - Roll No. 17 - 2023 Batch
Bloom Level | Score /2 | Key Feedback
1. Remember | 1 | SOB + edema + AV fistula exam excellent, vitals / systemic / investigations missing
2. Understand | 1 | SOB + edema described, fistula thrill / bruit not explained
3. Apply | 1 | AV fistula exam applied, no RFT / dialysis plan
4. Analyze | 1 | CKD pattern recognized, no differential table
5. Evaluate | 1 | AV fistula exam shows judgment, dialysis schedule contradiction missed
6. Create | 0 | No original product
**Total** | **5 / 12** | **Developing - Competent**
*Overall CBME Feedback for Roll 17 - Progression:*
- CASE 1 HTN + Headache + Edema 53F = 5/12, CASE 2 Appendicitis 15F = 5/12, CASE 3 Knee OA 61F = 5/12, *This portfolio = 5/12*
- *Progress flat, but AV Fistula Examination is your best work:* Radial Artery - Cephalic Vein, Left forearm, Inspection Scar +, Swelling +, No Redness, Palpation Thrill +, Auscultation Bruit + - that is exactly how a fistula should be examined, and no one else in this batch did it this well. SOB - MMRC III, on exertion, relieved rest, plus pitting edema feet + hands, plus oliguria 4 times/day, plus last dialysis 26/10/26 is also a good fluid overload story.
- *Critical learning from this case:* Two traps - 1) Contradictions - "Dysuria" is not "decreased urine", "3 times/week" is not "Monday & Thursday" - fix them before submitting. 2) You did the fistula exam but no vitals, no systemic exam, no RFT - in CKD + SOB, BP, SpO2, RR, lungs for crepitations, RFT, Hb, K are not optional. Add vitals + systemic exam + RFT + dialysis schedule clarification, and this case becomes 8-9/12.
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