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IM14.1-14 | Obesity — Assignment

CLINICAL SCENARIO

This assignment requires you to complete a structured clinical case report on a real or simulated patient presenting with overweight or obesity at a tertiary care general medicine outpatient clinic. You will apply the full clinical evaluation framework — history, examination, investigation, and management — using Asian-Indian standards throughout, and demonstrate competency in non-judgemental counselling. You may use a real patient encountered during your clinical posting (with appropriate anonymisation) or the structured simulated case provided in the scaffolding guide.

Instructions

Write a structured case report in the sections below. Use professional clinical language throughout. Apply Asian-Indian BMI and waist circumference thresholds — not Western cut-offs. Document every investigation with the clinical reason it was ordered and your interpretation of the result. Your management plan must be stepwise (lifestyle → pharmacotherapy → bariatric) with correct Indian thresholds for each step. In the counselling section, demonstrate non-judgemental, person-first language. Do not copy SDL text verbatim. Word limit: 1,200–1,600 words.

Length: 1,200–1,600 words across all sections

What to Submit

Section 1: Patient Identification and Anthropometric Classification

Guidance: State age, sex, and occupation. Calculate BMI. Apply Asian-Indian BMI thresholds (overweight ≥23 kg/m², obese ≥25 kg/m²) and classify the patient. Document waist circumference with the correct measurement technique and apply the sex-specific Asian-Indian cut-off (men ≥90 cm, women ≥80 cm). Briefly explain WHY Asian-Indian cut-offs are lower than Western thresholds. Approximately 100–150 words.

Section 2: Focused Obesity History

Guidance: Take a structured history across all 7 domains: (1) onset and duration of weight gain; (2) dietary history (types of food, meal pattern, liquid calories, ultra-processed food frequency, estimated caloric intake); (3) physical activity history (type, frequency, duration, barriers); (4) sleep history (duration, quality, snoring, witnessed apnoea); (5) complete medication list with attention to weight-gaining drugs (antipsychotics, steroids, insulin, antiepileptics); (6) family history of obesity, T2DM, thyroid disease; (7) targeted symptom review for secondary causes (cold intolerance/constipation/fatigue → hypothyroidism; irregular cycles/hirsutism/acne in women → PCOS; striae/hypertension/moon facies → Cushing). Document patient's motivation and previous weight-loss attempts. Approximately 300–350 words.

Section 3: Differential Diagnosis

Guidance: Generate a structured differential diagnosis separating primary (multifactorial/polygenic) obesity from secondary causes. For each secondary cause you consider, state: the specific clinical feature(s) that prompted this consideration, and whether you are moving it higher or lower on the differential and why. You must consider and address hypothyroidism, Cushing syndrome, PCOS (in women), and drug-induced obesity. You do not need to include rare monogenic causes unless clinical features suggest them. Approximately 150–200 words.

Section 4: Physical Examination Findings

Guidance: Document the complete physical examination relevant to obesity. Include: general appearance (body fat distribution pattern — central/peripheral/generalised); vital signs including BP with correctly-sized cuff (note that a standard cuff overestimates BP by 5–10 mmHg in arms >34 cm); anthropometric measurements with correct technique; skin findings (acanthosis nigricans, striae — colour and location, skin tags); endocrine signs (thyroid palpation, Cushingoid features); signs of complications (fundoscopy if available, peripheral pulses, ankle oedema). Approximately 200 words.

Section 5: Investigation Plan and Interpretation

Guidance: Present your investigation plan in two columns: (A) Secondary cause screen — state the specific test and the finding that would confirm each secondary cause; (B) Complication and risk screen — include fasting glucose/HbA1c, fasting lipid profile, liver function tests, renal function, and any additional tests based on symptoms (e.g., PSG for OSA if history suggests it). Interpret any investigation results you have obtained or that are provided in your simulated case. State the criteria for metabolic syndrome (IDF criteria) and whether your patient meets them. Approximately 250 words.

Section 6: Evidence-Based Management Plan

Guidance: Construct a stepwise, individualised management plan: STEP 1 — Lifestyle modification (prescribe a specific caloric deficit of 500–750 kcal/day, a physical activity target of ≥150 min/week moderate intensity, and at least two behavioural strategies such as food diary, meal timing, or sleep hygiene). STEP 2 — Pharmacotherapy: state the Asian-Indian threshold for initiating pharmacotherapy (BMI ≥27.5 with comorbidity or ≥32.5 without), and if met, name your first-choice agent with its mechanism and side-effect profile. STEP 3 — Bariatric surgery: state the Asian-Indian BMI threshold for referral (≥32.5 with comorbidity or ≥37.5 without) and whether your patient currently meets it. Include management of any obesity-related complications identified. Approximately 250–300 words.

Section 7: Patient Counselling — Non-Judgmental Communication

Guidance: Describe how you would counsel this patient about their weight and the management plan, demonstrating the 5As framework (Ask permission, Assess stage of change, Advise evidence-based plan, Agree on personalised goals, Assist with follow-up). Write one representative exchange (2–4 lines of dialogue) that shows how you would respond if the patient says: 'I have tried everything and always regain the weight. It's hopeless.' Your response should reframe non-adherence as a biological and environmental challenge, not a character failure. Use person-first language throughout. Approximately 150–200 words.

Grading Rubric — Clinical Obesity Case Report Rubric

Criterion	Points	Full-marks descriptor
Definition, Classification, and Anthropometric Accuracy (Section 1): Correctly applies Asian-Indian BMI thresholds (overweight ≥23, obese ≥25 kg/m²) and waist circumference cut-offs (men ≥90 cm, women ≥80 cm); explains why lower cut-offs apply to Indian patients.	15 pts	Asian-Indian cut-offs stated precisely and correctly; waist circumference technique and cut-off correct for sex; clear explanation of why South Asians accumulate visceral fat at lower BMI; BMI calculation demonstrated.
History and Differential Diagnosis (Sections 2–3): Structured obesity history covering all key domains; appropriate differential diagnosis including primary and secondary causes; prioritised based on clinical features.	20 pts	All 7 history domains covered (onset/duration, dietary, activity, sleep, medications, family history, secondary cause symptoms); differential lists ≥2 secondary causes with clinical rationale for inclusion/exclusion; prioritisation justified.
Physical Examination Findings (Section 4): Documents examination findings relevant to obesity severity, secondary causes, and complications; correct technique for anthropometric measurements.	15 pts	All anthropometric measurements documented with correct technique; examination targets secondary causes (thyroid, Cushingoid signs, PCOS features) and complications (acanthosis, BP, fundoscopy); findings linked to differential.
Investigation Plan and Interpretation (Section 5): Appropriate investigation selection for secondary causes and complication screening; correct interpretation of results.	20 pts	Investigation plan stratified by indication (secondary cause screen vs complication screen); named tests for each indication with correct result thresholds (e.g., TSH normal range, DST cortisol cut-off, metabolic syndrome criteria); interpretation of given results is accurate.
Management Plan (Section 6): Evidence-based stepwise management including lifestyle modification, pharmacotherapy indications, and bariatric thresholds; uses Asian-Indian BMI thresholds throughout.	20 pts	Stepwise plan: lifestyle modification first (dietary deficit quantified, physical activity prescription, behavioural strategies); pharmacotherapy with correct Indian threshold (BMI ≥27.5 with comorbidity or ≥32.5 without) and named preferred agent with rationale; bariatric threshold correctly stated (≥32.5 with comorbidity); complication-specific management addressed.
Counselling and Non-Judgemental Communication (Section 7): Demonstrates understanding of patient-centred, non-judgemental counselling; uses the 5As framework; acknowledges biological basis of non-adherence.	10 pts	5As framework applied; person-first language used; non-adherence explicitly reframed as biological/environmental not moral failure; specific example of how to respond when patient expresses frustration or shame about weight.

PEER REVIEW

Review your peer's obesity case report using the provided rubric. For each section, assign a score and write one specific comment explaining your assessment — do not simply copy the rubric descriptor. Pay particular attention to: (1) whether Asian-Indian BMI and waist circumference thresholds are correctly applied in Section 1; (2) whether the secondary cause differential is clinically reasoned for the specific case in Section 3; (3) whether the pharmacotherapy and bariatric thresholds in Section 6 use Asian-Indian values (BMI ≥27.5/≥32.5 for pharmacotherapy, ≥32.5/≥37.5 for surgery) rather than Western cut-offs; (4) whether the counselling section in Section 7 demonstrates non-judgemental, person-first language with a specific response to expressed hopelessness. Complete your peer review within 72 hours.