24/10/2026
Here is the 6-point CBME evaluation for *2023 Batch - Roll No. 2* - Portfolio: *CASE 2 - 75M, HTN 10 Years - Telmisartan Irregular, CKD - 1 Year, Haemodialysis - 13 Months, Oliguria <200 ml/day, Appetite Decreased, Pallor Mild +, Pedal Edema B/L +, BP 160/90, AV Fistula (Lt) Wrist - Thrill + Bruit +, Provisional Diagnosis: Hypertensive Nephrosclerosis*
Based on the anonymized text you pasted - this is the second case you sent after the 70M SOB case, with the previous evaluation pasted above it. Score 0-2 per level. Total /12.
### 1. Remember - Knowledge Recall
*Evidence in portfolio:*
- Past H/o: K/C/O HTN since 10 years (Tab Telmisartan taken) irregular medication, CKD - 1 yr ago, hemodialysis 13 months, N/K/C/O TB / asthma / COPD / epilepsy, No major surgeries, Personal H/o: Appetite decreased, Diet mixed, Sleep disturbed, B & B - Bowel regular, Bladder - oliguria (<200ml/day), H/o alcohol 10 years back, Family H/o: Father has T2 DM, General examination: O/E Pt c/c well oriented to TPP, P (+) mild, I / C / C / L (-), E (+) B/L pedal edema, Vitals: BP 160/90 mmHg, PR 76 bpm, RR 20/min, Temp Afebrile, SpO2 97% on RA, AV fistula (Lt) wrist: Inspection - surgical scar, no prominent veins, no redness, ulceration, discharge, Palpation - palpable continuous thrill, fistula not tender / warm, Auscultation - bruit, Systemic examination: CVS S1 S2 (+) no murmur, CNS NFND, RS NVBS (+) BAE (+), P/A soft, NT, Provisional diagnosis - hypertensive nephrosclerosis.
- Good details: HTN duration - 10 years, irregular medication - important, CKD 1 year, dialysis 13 months, oliguria <200 ml/day - quantified, appetite decreased, sleep disturbed, alcohol 10 years back, family - Father T2 DM, PICCLE - P (+) mild, E (+) B/L pedal edema - complete, vitals - all 5 - BP, PR, RR, Temp, SpO2 - complete, AV fistula - Lt wrist - Inspection + Palpation + Auscultation - scar, no redness / ulcer / discharge, thrill continuous, not tender / warm, bruit - complete, systemic exam - all 4 systems, provisional diagnosis given.
- Gaps: *No Demographics in this paste - Age / Sex / Occupation / Chief Complaints / HOPI missing* - if this is a new patient, age / sex / C/C / HOPI are missing. If this is the same 70M from Case 1, it is not stated - 70M + HTN 3 years in Case 1 vs HTN 10 years here - contradiction. *No Investigations - RFT, CBC, Hb, Electrolytes, eGFR, USG kidney.* *No Last dialysis, No Dialysis frequency, No Dry weight.* *No Cause of CKD - why hypertensive nephrosclerosis? - no USG, no urine protein.* *No Oedema grading* - unlike Case 1 Gr III - not graded here.
*Score: 1 / 2*
- Partial recall - past history + fistula + vitals + systemic exam good, but demographics / C/C / HOPI / investigations missing.
- *Next target:* Always start with Age / Sex / Occupation / C/C / HOPI - never start with Past H/o. If this is a new patient, write: e.g. 65M, SOB, edema, oliguria - with duration. If this is the same patient as Case 1, reconcile HTN 3 years vs 10 years. Always record Investigations - RFT - urea, creatinine, eGFR, CBC - Hb - Pallor mild + needs Hb, Electrolytes - K, Ca, Phosphate, Urine protein, USG abdomen - kidney size - small kidneys in nephrosclerosis. Always record Dialysis - times/week, last dialysis, dry weight. Always grade Edema - pitting, up to ankle / leg, Gr I / II / III.
### 2. Understand - Comprehension
*Evidence in portfolio:*
- HTN 10 years irregular Telmisartan -> CKD 1 year -> dialysis 13 months -> oliguria <200 ml/day, pallor, edema - sequence described.
- But no explanation in own words of why irregular HTN causes CKD, why CKD causes oliguria, pallor, edema.
- No explanation of hypertensive nephrosclerosis - not explained.
*Score: 1 / 2*
- Partial comprehension.
- *Next target:* Explain: HTN 10 years, irregular Telmisartan = BP uncontrolled, high pressure damages kidney small vessels over years -> hypertensive nephrosclerosis -> kidneys shrink, lose function -> CKD. Explain: CKD -> kidneys cannot make urine -> oliguria <200 ml/day, cannot clear water / salt -> pedal edema, cannot make erythropoietin -> Pallor mild + anaemia, appetite decreased, sleep disturbed. Explain: AV Fistula Lt wrist - Thrill continuous + Bruit = fistula working, Not tender / warm + No redness / ulcer / discharge = no infection. Explain: Father T2 DM = family risk for DM / HTN / CKD, need to check blood sugar. Explain: Alcohol 10 years back - past, not current, less likely cause now.
### 3. Apply - Application to Patient Care
*Evidence in portfolio:*
- Haemodialysis 13 months - mentioned.
- AV Fistula Examination done - Inspection + Palpation + Auscultation.
- But no student plan - no investigation plan, no management plan.
- No application of BP 160/90 + irregular Telmisartan to care - no BP control plan.
*Score: 1 / 2*
- Partial application - fistula exam + dialysis applied, but no care plan.
- *Next target:* Add: RFT, CBC, Electrolytes, ECG, Chest X-ray, USG kidney, Urine protein. Add management - Continue dialysis - clarify times/week, do not miss, Take Telmisartan regularly - irregular = cause of CKD progression, BP monitoring daily, target BP, Fluid restriction, low salt, daily weight, check fistula daily - thrill / bruit, keep clean, no BP / blood draw on left arm, Treat anaemia - iron, erythropoietin, check Hb, Diet - low salt, low potassium, Follow-up, Refer - Nephrology. Add: If BP 160/90 + oliguria + edema - urgent - check lungs, weight gain, K, last dialysis.
### 4. Analyze - Differentiation & Interpretation
*Evidence in portfolio:*
- Provisional diagnosis - hypertensive nephrosclerosis - given, better than Case 1.
- But no differential list.
- No analysis of alternative causes: Hypertensive nephrosclerosis vs Diabetic nephropathy vs Chronic glomerulonephritis vs Obstructive uropathy.
- No analysis of why hypertensive nephrosclerosis - HTN 10 years, irregular medication - vs diabetic - Father T2 DM - not differentiated.
*Score: 1 / 2*
- Partial analysis - hypertensive nephrosclerosis named, but not differentiated.
- *Next target:* Add differential table: Hypertensive Nephrosclerosis - supports HTN 10 years, irregular Telmisartan, CKD 1 year, dialysis 13 months, BP 160/90, oliguria <200 ml/day, pallor, edema; against - no USG - small kidneys, no urine protein, no retinal changes, no LVH given. Diabetic Nephropathy - supports Father T2 DM, CKD, edema; against - N/K/C/O DM in patient - you wrote N/K/C/O TB / asthma / COPD / epilepsy, but DM not stated as N/K/C/O for patient - need to clarify patient DM status, no blood sugar given. Chronic Glomerulonephritis - supports CKD, edema, HTN, oliguria; against - no haematuria, proteinuria mentioned. Obstructive Uropathy - supports oliguria; against - no dysuria, pain, USG not given. Must analyze: Is HTN the cause of CKD or the result of CKD? 10 years HTN before 1 year CKD suggests HTN caused CKD, but CKD also worsens HTN - bidirectional.
### 5. Evaluate - Judgment & Reflection
*Evidence in portfolio:*
- "Irregular medication" - shows judgment - you flagged non-adherence as cause.
- AV Fistula - Thrill + Bruit, Not tender / warm, No redness / ulcer / discharge - shows judgment - fistula working, not infected.
- Negatives - N/K/C/O TB / asthma / COPD / epilepsy, No major surgeries - show judgment.
- But no judgment on BP 160/90 - still high despite Telmisartan - not flagged as uncontrolled.
- No judgment on missing demographics / C/C / HOPI - not evaluated.
- No reflection.
*Score: 1 / 2*
- Partial evaluation - irregular medication + fistula show judgment, but BP / missing history missed.
- *Next target:* Add: Can I label hypertensive nephrosclerosis without USG kidney, urine protein, retinal exam, blood sugar? What is most urgent - BP 160/90 + oliguria + edema + dialysis - is he in fluid overload / hyperkalaemia? What is the risk if I miss diabetic nephropathy - Father T2 DM, patient DM status unclear? What would I do differently - ask patient DM status, check blood sugar, check USG kidney, check urine protein, check BP twice, ask about dialysis frequency, missed dialysis? Reflection on irregular medication - why irregular? Cost, side effects, forgetfulness, no symptoms? - counselling needed, 10 years HTN -> 1 year CKD - preventable if BP controlled?
### 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: HTN 10 Years Irregular -> CKD -> Dialysis -> Oliguria + Edema + Pallor -> Hypertensive Nephrosclerosis vs Diabetic Nephropathy -> Examination -> RFT + USG + Urine Protein -> Management, OR patient education sheet for HTN + CKD on Dialysis - Take Telmisartan daily, BP monitoring, fluid / salt, AV Fistula Care, when to go to hospital - breathlessness, swelling, urine ↓, OR Socratic questions like Roll 12 Case 1.
### Summary Sheet - Roll No. 2 - 2023 Batch
Bloom Level | Score /2 | Key Feedback
1. Remember | 1 | Fistula + vitals + systemic good, demographics / C/C / HOPI / investigations missing
2. Understand | 1 | HTN -> CKD sequence described, nephrosclerosis mechanism not explained
3. Apply | 1 | Fistula + dialysis applied, no RFT / BP control plan
4. Analyze | 1 | Hypertensive nephrosclerosis named, no differential table
5. Evaluate | 1 | Irregular medication + fistula show judgment, BP 160/90 / DM status 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, *This portfolio = 5/12*
- *Progress flat, but fistula exam is now complete:* Inspection - surgical scar, no prominent veins, no redness, ulceration, discharge, Palpation - palpable continuous thrill, fistula not tender / warm, Auscultation - bruit - that is the full fistula triad, and you did it. And you finally wrote a Provisional Diagnosis - hypertensive nephrosclerosis - which Case 1 did not have. And "Irregular medication" is a good catch - 10 years HTN, irregular Telmisartan -> CKD.
- *Critical learning from this case:* You pasted no Age / Sex / C/C / HOPI for this patient - if this is a new patient, that is half the case missing. If this is the same 70M from Case 1, you have a contradiction - HTN 3 years in Case 1 vs HTN 10 years here. And you have not proved hypertensive nephrosclerosis - you need USG - small kidneys, urine protein, blood sugar - to rule out diabetic nephropathy, especially with Father T2 DM. Add Demographics + C/C + HOPI + RFT + USG + Blood sugar, and this case becomes 8-9/12.
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