19/10/2026
Here is the 6-point CBME evaluation for *2023 Batch - Roll No. 2* - Portfolio: *CASE 3 - 49F, Homemaker, ↓ Urine Output - 2 Years, Mild Swelling Both Feet - 7 Days, Breathlessness - 3 Days, T2DM + HTN - 8 Years, Pedal Edema - 5 Years, Oliguria - 4 Years, CKD - 3 Years, Haemodialysis - 18 Months, 3 Times/Week, 4 Hrs/Session, Left Radiocephalic AV Fistula, Breathlessness MMRC III + Orthopnoea, Telmisartan + Furosemide*
Based on the anonymized text you pasted. Score 0-2 per level. Total /12.
### 1. Remember - Knowledge Recall
*Evidence in portfolio:*
- Age: 49 years, F, Occupation: Homemaker, C/C: ↓ urine output - 2 years, Mild swelling of both feet - 7 days, Breathlessness - 3 days, HOPI: Asymptomatic 8 years ago then diagnosed with T-2 diabetes and HTN, 5 years ago developed bilateral pedal edema initially involving ankles and progressing to legs, She did not go to check up as she ignored her mild symptoms & continued household work (Tab Telmisartan), Swelling was insidious in onset, gradually progressive, more in evening & relieved by rest, 4 years ago noticed oliguria, progressive, No H/o dysuria, hematuria, UTI, 3 years ago diagnosed with CKD - blood test, Since then she is on hemodialysis - 18 months, 3 times/week, 4 hrs per session, through left radiocephalic AV fistula, Breathlessness since 3 days, gradually progressive on minimal activity (MMRC grade III) (walking) associated c orthopnea, No H/o fever, cough, chest pain, wheezing, Notes: serum creatinine, urea, electrolytes, diuretics - furosemide, fluids.
- Good details: Timeline - 8 years T2DM + HTN, 5 years edema ankles -> legs, 4 years oliguria, 3 years CKD, 18 months dialysis - chronology clear, dialysis details - 3 times/week, 4 hrs/session, left radiocephalic AV fistula - complete, edema pattern - insidious, gradually progressive, more evening, relieved rest, ankles -> legs, oliguria - progressive, no dysuria, hematuria, UTI, breathlessness - 3 days, gradually progressive, minimal activity, MMRC III, walking, orthopnoea, negatives - No fever, cough, chest pain, wheezing, drugs - Telmisartan, Furosemide, notes - serum creatinine, urea, electrolytes, fluids.
- Gaps: *No Past History section - past history is in HOPI only.* *No Personal History - Appetite, Diet, Sleep, Bowel & Bladder, Addictions - missing.* *No Family History.* *No General Examination - PICCLE missing - Pallor? Edema grading?* *No Vitals - BP, PR, RR, Temp, SpO2 missing - critical in CKD + breathlessness + HTN + DM.* *No Systemic Examination - CVS, CNS, RS, P/A missing - critical in breathlessness + orthopnoea.* *No AV Fistula Examination - Thrill / Bruit - missing - unlike Case 2.* *No Investigation RESULTS - serum creatinine, urea, electrolytes mentioned as notes, but no values.* *No Provisional Diagnosis - Diabetic nephropathy? Hypertensive nephrosclerosis? - not written.* *C/C contradiction - ↓ urine output 2 years vs oliguria 4 years ago* - which one?
*Score: 1 / 2*
- Partial recall - timeline + dialysis details + breathlessness pattern good, but exam, vitals, personal / family history, investigations results, diagnosis missing.
- *Next target:* Always record Personal History - Appetite, Diet, Sleep, Bowel & Bladder, Addictions, Family History - DM / HTN in family. Always record General Examination - PICCLE - Pallor? Edema? - and grade edema. Always record Vitals - all 5 - BP, PR, RR, Temp, SpO2 - in CKD + breathlessness + HTN + DM. Always do Systemic Examination - CVS, CNS, RS, P/A - especially RS - crepitations? - in breathlessness + orthopnoea. Always do AV Fistula Examination - Inspection + Palpation + Auscultation - Thrill / Bruit. Always record Investigation RESULTS - serum creatinine - value, urea - value, electrolytes - K, Na, Ca, Hb, blood sugar, HbA1c. Always write Provisional Diagnosis. Clean contradiction - ↓ urine 2 years vs oliguria 4 years ago.
### 2. Understand - Comprehension
*Evidence in portfolio:*
- T2DM + HTN 8 years -> edema 5 years -> oliguria 4 years -> CKD 3 years -> dialysis 18 months -> breathlessness 3 days + orthopnoea - sequence described.
- But no explanation in own words of why DM + HTN cause CKD, why CKD causes edema, oliguria, breathlessness, orthopnoea.
- No explanation of MMRC III, left radiocephalic AV fistula, Furosemide, Telmisartan - not explained.
*Score: 1 / 2*
- Partial comprehension.
- *Next target:* Explain: T2DM + HTN 8 years = both damage kidney small vessels over years -> diabetic nephropathy + hypertensive nephrosclerosis -> CKD. Explain: CKD -> kidneys cannot clear water / salt -> bilateral pedal edema ankles -> legs, more evening, relieved rest, cannot make urine -> oliguria progressive. Explain: Breathlessness 3 days, MMRC III, on minimal activity, walking, orthopnoea = fluid overload in lungs, pulmonary edema, cannot lie flat. Explain: MMRC III = SOB on walking 100m / few minutes, stops for breath. Explain: Left radiocephalic AV fistula = radial artery to cephalic vein in left wrist, for dialysis. Explain: Dialysis 3 times/week, 4 hrs/session = removes water, urea, creatinine, electrolytes. Explain: Telmisartan = for HTN + kidney protection, Furosemide = diuretic, removes fluid, reduces edema / breathlessness. Explain: Ignored mild symptoms, continued household work = delayed care, CKD progressed.
### 3. Apply - Application to Patient Care
*Evidence in portfolio:*
- Dialysis - 18 months, 3 times/week, 4 hrs/session, left radiocephalic AV fistula - mentioned.
- Notes: serum creatinine, urea, electrolytes, diuretics - furosemide, fluids - mentioned.
- But no student plan - no investigation plan, no management plan written by student.
- No application of breathlessness MMRC III + orthopnoea to care - no urgent dialysis, no lung check.
*Score: 1 / 2*
- Partial application - dialysis + notes applied, but no care plan.
- *Next target:* Add: CBC - Hb, RFT - serum creatinine, urea, eGFR, Electrolytes - K, Na, Ca, Phosphate, Blood sugar - FBS, PPBS, HbA1c, ECG, Chest X-ray - pulmonary edema, USG kidney. Add management - Urgent dialysis - breathlessness + orthopnoea + edema, do not miss, Fluid restriction, low salt, daily weight, check BP, blood sugar daily, Continue Telmisartan, Furosemide - check K, creatinine, Check fistula daily - thrill / bruit, no BP / blood draw on left arm, Diet - low salt, low potassium, diabetic diet, Follow-up, Refer - Nephrology / Medicine. Add: If breathlessness + orthopnoea + SpO2 low - urgent - check lungs for crepitations, SpO2, Chest X-ray, urgent dialysis.
### 4. Analyze - Differentiation & Interpretation
*Evidence in portfolio:*
- No provisional diagnosis, no differential list.
- No analysis of alternative causes: Diabetic nephropathy vs Hypertensive nephrosclerosis vs Chronic glomerulonephritis.
- No analysis of breathlessness causes: Fluid overload / Pulmonary edema vs Heart failure vs Anaemia vs Pneumonia.
*Score: 1 / 2*
- Partial analysis - DM + HTN -> CKD pattern recognized, but not differentiated.
- *Next target:* Add differential table: Diabetic Nephropathy - supports 49F, T2DM 8 years, HTN 8 years, edema 5 years ankles -> legs, oliguria 4 years, CKD 3 years, dialysis 18 months; against - no urine protein, HbA1c, retinal changes given. Hypertensive Nephrosclerosis - supports HTN 8 years, Telmisartan, CKD, edema, oliguria; against - DM also present, need to decide which is primary. Chronic Glomerulonephritis - supports CKD, edema, HTN, oliguria; against - no haematuria, proteinuria, UTI mentioned - No dysuria, hematuria, UTI. Heart Failure - supports breathlessness MMRC III, orthopnoea, edema; against - No chest pain, wheezing, fever, cough, no CVS / RS exam. Pneumonia - supports breathlessness; against - No fever, cough, wheezing, chest pain. Must analyze: Is breathlessness due to fluid overload from CKD / missed dialysis, or heart failure from HTN + DM, or anaemia? Is edema due to CKD, DM, HTN, or Telmisartan / Amlodipine?
### 5. Evaluate - Judgment & Reflection
*Evidence in portfolio:*
- Negatives - No dysuria, hematuria, UTI, No fever, cough, chest pain, wheezing - show judgment - you ruled out UTI / lung infection.
- "She did not go to check up as she ignored her mild symptoms & continued household work" - shows judgment - you flagged delayed care.
- Dialysis details - 3 times/week, 4 hrs/session - shows judgment - you know dialysis prescription.
- But no judgment on breathlessness MMRC III + orthopnoea - not flagged as urgent.
- No judgment on C/C contradiction - ↓ urine 2 years vs oliguria 4 years - not evaluated.
- No reflection.
*Score: 1 / 2*
- Partial evaluation - negatives + delayed care + dialysis details show judgment, but breathlessness urgency / contradiction missed.
- *Next target:* Add: Can I label CKD without RFT values, USG, urine protein? What is most urgent - Breathlessness 3 days, MMRC III, orthopnoea, edema 7 days, ↓ urine - is she in pulmonary edema / fluid overload / hyperkalaemia? What is the risk if I miss pulmonary edema / heart failure in a 49F on dialysis with breathlessness + orthopnoea? What would I do differently - check vitals, check lungs for crepitations, check weight gain, check last dialysis, missed dialysis?, check fistula, ask about PND, chest pain? Reflection on 49F homemaker - 8 years DM + HTN, ignored mild symptoms, continued household work - gender, family, household burden, health-seeking, need for counselling, diet, BP / sugar monitoring?
### 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: T2DM + HTN 8 Years -> Edema 5 Years -> Oliguria 4 Years -> CKD 3 Years -> Dialysis -> Breathlessness MMRC III + Orthopnoea -> Fluid Overload vs Heart Failure -> Examination -> RFT + Chest X-ray + AV Fistula Check -> Urgent Dialysis, OR patient education sheet for DM + HTN + CKD on Dialysis - Daily Monitoring - weight, urine, BP, blood sugar, fluid / salt, diabetic diet, AV Fistula Care, when to go to hospital - breathlessness, swelling, urine ↓, OR Socratic questions.
### Summary Sheet - Roll No. 2 - 2023 Batch
Bloom Level | Score /2 | Key Feedback
1. Remember | 1 | Timeline + dialysis details good, exam / vitals / results / diagnosis missing
2. Understand | 1 | DM + HTN -> CKD sequence described, mechanism not explained
3. Apply | 1 | Dialysis + notes applied, no urgent breathlessness plan
4. Analyze | 1 | DM + HTN -> CKD recognized, no differential table
5. Evaluate | 1 | Negatives + delayed care show judgment, breathlessness urgency missed
6. Create | 0 | No original product
**Total** | **5 / 12** | **Developing - Competent**
*Overall CBME Feedback for Roll 2 - Progression:*
- CASE 1 SOB + Face Swelling + Edema 70M = 5/12, CASE 2 HTN 10 Years + CKD + Dialysis = 5/12, *This portfolio = 5/12*
- *Progress flat, but timeline + dialysis prescription are your best so far:* 8 years T2DM + HTN, 5 years edema ankles -> legs, 4 years oliguria, 3 years CKD, 18 months dialysis, 3 times/week, 4 hrs/session, left radiocephalic AV fistula - that is a textbook DM + HTN -> CKD timeline, and you captured it with the dialysis prescription. And "She ignored mild symptoms & continued household work" is a good social history catch - delayed care.
- *Critical learning from this case:* You have breathlessness MMRC III + orthopnoea for 3 days - that is a red flag for pulmonary edema - but you have no vitals, no systemic exam, no fistula exam, no RFT values. In CKD + breathlessness, vitals + RS - crepitations? - are not optional. And you have no diagnosis - diabetic nephropathy or hypertensive nephrosclerosis? Add PICCLE + Vitals + Systemic Exam + Fistula Exam + RFT / HbA1c RESULTS + Provisional Diagnosis, and this case becomes 8-9/12.
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