29/10/2026
Here is the 6-point CBME evaluation for *2023 Batch - Roll No. 2* - Portfolio: *CASE 5 - 50F, Housewife, Edema Legs - 1 Year, Urine Output Decreased - 5 Days, Pitting Edema, HTN + CKD - 2 Years, Bilateral Pedal Edema - 1 Year, Oliguria - 1 Year, CKD by Blood Test - 8 Months, Haemodialysis - 2 Times/Week, 4 Hrs/Session, Through AV Fistula, BP 160/90, RR 29/min, SpO2 99% on RA, Oliguria 200 ml/day, Provisional: CKD Stage 5D on MHD - For AV Fistula Assessment*
Based on the anonymized text you pasted - Date: 20/10/2026. Score 0-2 per level. Total /12.
### 1. Remember - Knowledge Recall
*Evidence in portfolio:*
- Demography: 50 yrs / Female / Housewife, Date: 20/10/2026, Chief complaints: Edema (swelling of legs - 1 yr), Urine output decreased - 5 days, Pitting edema, HOPI: Pt was apparently asymptomatic 2 yrs ago then she diagnosed with hypertension and CKD, 1 yr ago she developed mild bilateral pedal edema, initially involving ankle & progressive to leg, Swelling was insidious on onset, gradually progressive, bilateral edema, non pitting, relieved by rest, 1 yr ago she noticed oliguria, progressive nature, Since 8 months ago she was diagnosed with CKD by blood test, 2 times/wk, 4 hrs per session through AV fistula, Past H/O: K/C/O HTN since 2 yrs, CKD for 2 yrs - on haemodialysis, N/K/C/O - TB, asthma, epilepsy, Personal H/O: Appetite ↓, Diet - mixed, Sleep - disturbed, Bowels - normal, Bladder - oliguria - 200 ml/day, Addiction - No, Family H/o = NO, General Examination: O/E Pt is C/C/C well oriented to T/P/P, P I C C I E (-) (-) (-) (-) (-) (+), Pedal Edema, Pitting edema, Vitals: BP - 160/90 mmHg, RR - 29/min, Temp - 98F, SpO2 - 99% on RA, Systemic Examination: CVS - S1 S2 (+), CNS - NFND, RS - NVBS, BAE (+), P/A - Soft NT, AV Fistula examination (Cephalic & Radial vein artery): Inspection: surgical scar, No prominent, No redness, Palpation: palpable continuous / mild, swelling present, Provisional: CKD Stage 5D on MHD - For AV fistula assessment.
- Good details: Age / Sex / Occupation - 50F, Housewife, Date - 20/10/2026, C/C - Edema 1 year, Urine decreased 5 days, Pitting edema, Timeline - 2 years HTN + CKD, 1 year edema ankles -> legs, 1 year oliguria, 8 months CKD by blood test, Dialysis - 2 times/wk, 4 hrs/session, AV fistula - complete, Edema pattern - insidious, gradually progressive, bilateral, ankle -> leg, relieved by rest, Oliguria - 200 ml/day - quantified, Personal - Appetite ↓, Diet mixed, Sleep disturbed, Bowels normal, Bladder oliguria, Addiction No, PICCLE - E (+) only, rest (-) - complete, Vitals - BP, RR, Temp, SpO2 - complete, Systemic - all 4 systems, AV Fistula - Inspection + Palpation - scar, no prominent, no redness, palpable continuous, mild swelling, Provisional - CKD Stage 5D on MHD - For AV fistula assessment - specific.
- Gaps: *Contradictions - C/C: Pitting edema vs HOPI: non pitting edema* - which one? *C/C: Urine decreased 5 days vs HOPI: Oliguria 1 year* - which one? *HOPI: CKD diagnosed 2 years ago vs CKD diagnosed by blood test 8 months ago* - which one? *No PR - Pulse Rate missing from vitals.* *No Investigations - RFT, CBC, Hb, Electrolytes, eGFR, USG - missing.* *No AV Fistula Auscultation - Bruit - missing - unlike Case 2.* *No AV Fistula Palpation - Thrill - "palpable continuous / mild" - continuous what? - thrill? - not clear.* *No Last dialysis, No Dry weight.* *No Cause of CKD - HTN only? DM? - missing.*
*Score: 1 / 2*
- Partial recall - demographics + timeline + dialysis + AV fistula + vitals good, but contradictions, PR, investigations, bruit missing.
- *Next target:* Clean contradictions before submitting - Pitting or non-pitting? Urine decreased 5 days or 1 year? CKD diagnosed 2 years or 8 months ago? Always record PR - Pulse Rate - e.g. 78 bpm - not missing. Always record Investigations - RFT - urea, creatinine, eGFR, CBC - Hb, Electrolytes - K, Ca, Phosphate, USG kidney. Always do AV Fistula Examination - Inspection + Palpation (Thrill) + Auscultation (Bruit) - Thrill continuous + Bruit = working. Always record Last dialysis, Dry weight, Dialysis frequency. Always record Cause of CKD - HTN, DM, Glomerulonephritis?
### 2. Understand - Comprehension
*Evidence in portfolio:*
- HTN + CKD 2 years -> edema 1 year ankles -> legs -> oliguria 1 year -> dialysis 2 times/week, 4 hrs/session -> CKD Stage 5D - sequence described.
- But no explanation in own words of why HTN causes CKD, why CKD causes edema, oliguria, appetite ↓, sleep disturbed.
- No explanation of CKD Stage 5D, MHD, AV fistula, pitting vs non-pitting - not explained.
*Score: 1 / 2*
- Partial comprehension.
- *Next target:* Explain: HTN 2 years = high pressure damages kidney small vessels -> CKD. Explain: CKD Stage 5D = End Stage Renal Disease, eGFR <15, D = on Dialysis, MHD = Maintenance Haemodialysis. Explain: CKD -> kidneys cannot clear water / salt -> bilateral pedal edema ankles -> legs, insidious, gradually progressive, relieved by rest, cannot make urine -> oliguria 200 ml/day. Explain: Appetite ↓, Sleep disturbed = uraemia, fluid overload, breathlessness. Explain: Pitting edema = fluid in tissues, pit on pressing - CKD / cardiac, Non-pitting = lymphoedema / myxoedema - you wrote both, need to decide which. Explain: AV Fistula - Cephalic vein + Radial artery - for dialysis, Palpable continuous thrill + Bruit = working, Mild swelling present = need to check for infection / thrombosis.
### 3. Apply - Application to Patient Care
*Evidence in portfolio:*
- Dialysis - 2 times/wk, 4 hrs/session, AV fistula - mentioned.
- Provisional - For AV fistula assessment - mentioned.
- But no student plan - no investigation plan, no management plan.
- No application of BP 160/90 + RR 29/min to care - no BP control, no lung check.
*Score: 1 / 2*
- Partial application - dialysis + fistula assessment applied, but no care plan.
- *Next target:* Add: RFT, CBC, Electrolytes, ECG, Chest X-ray, USG kidney, AV Fistula Doppler if needed. Add management - Continue dialysis - clarify times/week, do not miss, Take antihypertensive regularly, BP monitoring daily, Fluid restriction, low salt, daily weight, check fistula daily - thrill / bruit, keep clean, no BP / blood draw on fistula arm, Treat anaemia, Diet - low salt, low potassium, Follow-up, Refer - Nephrology. Add: If BP 160/90 + RR 29/min + edema + oliguria - urgent - check lungs for crepitations, SpO2, weight gain, K, last dialysis.
### 4. Analyze - Differentiation & Interpretation
*Evidence in portfolio:*
- Provisional: CKD Stage 5D on MHD - For AV fistula assessment - specific, better than Case 2.
- But no differential list.
- No analysis of alternative causes: Hypertensive nephrosclerosis vs Diabetic nephropathy vs Chronic glomerulonephritis.
- No analysis of fistula - working vs thrombosed vs infected - not differentiated.
- No analysis of RR 29/min - tachypnoea - why? - not analyzed.
*Score: 1 / 2*
- Partial analysis - CKD Stage 5D named, but not differentiated.
- *Next target:* Add differential table: Hypertensive Nephrosclerosis - supports HTN 2 years, CKD 2 years, edema 1 year, oliguria 1 year, BP 160/90; against - no USG - small kidneys, no urine protein given. Diabetic Nephropathy - supports CKD, edema, oliguria; against - N/K/C/O DM - you wrote N/K/C/O TB, asthma, epilepsy, but DM not stated - need to clarify patient DM status. Chronic Glomerulonephritis - supports CKD, edema, HTN, oliguria; against - no haematuria, proteinuria mentioned. AV Fistula - Working - supports palpable continuous thrill, surgical scar, no redness; against - mild swelling present, no bruit given - need bruit to confirm. AV Fistula - Thrombosed - supports mild swelling, no bruit? - need to check thrill / bruit. AV Fistula - Infected - supports swelling; against - no redness, no fever, temp 98F. Must analyze: Is RR 29/min due to fluid overload / pulmonary edema, anaemia, or acidosis? Is edema pitting or non-pitting?
### 5. Evaluate - Judgment & Reflection
*Evidence in portfolio:*
- Negatives - N/K/C/O TB, asthma, epilepsy - show judgment.
- PICCLE - E (+) only, rest (-) - shows judgment.
- "For AV fistula assessment" - shows judgment - you know the purpose of the case.
- But no judgment on contradictions - pitting vs non-pitting, urine 5 days vs 1 year, CKD 2 years vs 8 months - not evaluated.
- No judgment on BP 160/90 + RR 29/min - not flagged as urgent.
- No reflection.
*Score: 1 / 2*
- Partial evaluation - negatives + fistula purpose show judgment, but contradictions / vitals missed.
- *Next target:* Add: Can I label CKD Stage 5D without RFT - eGFR, USG, urine protein? What is most urgent - BP 160/90 + RR 29/min + edema + oliguria 200 ml/day - is she in fluid overload / pulmonary edema / hyperkalaemia? What is the risk if I miss fistula thrombosis - dialysis failure? What is the risk if I miss fistula infection - swelling + redness + fever? What would I do differently - check PR, check bruit, check thrill clearly, check last dialysis, missed dialysis?, check lungs for crepitations, check weight gain? Reflection on 50F Housewife - 2 years HTN + CKD, on dialysis, appetite ↓, sleep disturbed - impact on work, family, household, need for counselling, diet, BP 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: HTN 2 Years -> CKD -> Edema 1 Year -> Oliguria -> Dialysis -> AV Fistula Assessment -> Working vs Thrombosed vs Infected -> Management, OR patient education sheet for CKD Stage 5D on MHD - Dialysis, BP monitoring, fluid / salt, AV Fistula Care - check thrill / bruit daily, keep clean, no BP / blood draw on fistula arm, when to go to hospital - breathlessness, swelling, urine ↓, fistula pain / redness / no thrill.
### Summary Sheet - Roll No. 2 - 2023 Batch
Bloom Level | Score /2 | Key Feedback
1. Remember | 1 | Timeline + dialysis + fistula good, contradictions, PR, bruit missing
2. Understand | 1 | HTN -> CKD sequence described, Stage 5D / MHD not explained
3. Apply | 1 | Dialysis + fistula applied, no BP / RR plan
4. Analyze | 1 | CKD Stage 5D named, no differential / fistula table
5. Evaluate | 1 | Negatives + fistula purpose show judgment, contradictions / vitals 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 + CKD + Dialysis = 5/12, CASE 3 T2DM + HTN + CKD + Breathlessness 49F = 5/12, CASE 4 Hip Fracture 80F = 6/12, *This portfolio = 5/12*
- *Progress flat, but staging is now correct:* Provisional: CKD Stage 5D on MHD - For AV fistula assessment - that is the first time you staged CKD correctly - Stage 5D = End Stage on Dialysis - and you stated the purpose - AV fistula assessment. And Dialysis - 2 times/wk, 4 hrs/session, AV fistula - is now routine for you.
- *Critical learning from this case:* Three contradictions - Pitting vs Non-pitting edema, Urine decreased 5 days vs 1 year, CKD diagnosed 2 years vs 8 months - fix them before submitting. And you missed the two vitals that matter most in CKD + edema - PR and Bruit. In AV fistula assessment, Thrill + Bruit are the case - you have "palpable continuous / mild" - continuous what? - and no bruit. Add PR + Bruit + RFT RESULTS + Contradiction fix, and this case becomes 8-9/12.
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