QUESTION 1 - BLOOD COUNT TEST
From the information given, the diagnosis I would give to the patient would be
Chronic Kidney Disease (CKD). This condition happens when the kidneys have severe
damage that results in them progressively getting worse and losing the ability to
function properly. One of the complications of CKD is hypocalcemia, a disorder
associated with above normal calcium level activity in the circulatory system.
Hypocalcemia comes from hyperparathyroidism, which is overactivation in one of the
four parathyroid glands located in the throat. When the parathyroid glands are
functioning as normal, they release a parathyroid hormone (PTH) that is critical for
maintaining healthy calcium levels in the blood and urine. In hypocalcemia, the
overactivation in the glands causes too much PTH in the blood thus rising calcium
levels to an unhealthy amount (NIDDK, 2019) The imbalance in calcium is related to
CKD as it causes issues with the kidneys. When too much calcium builds up in the
urine, crystals form in the kidneys which eventually leads to kidney stones. If these
calcium levels reach severe peaks, the kidneys lose their ability to cleanse the blood
and eliminate fluids. Chronic Kidney Disease also provides an explanation for above
normal plasma levels. Due to the long period of time damage to the kidneys occurs
over, CKD is considered a chronic illness. In chronic illnesses, the concentration of
fibroblast growth factors change thus increasing plasma levels. In CKD, it is fibroblast
growth factors 19 and 20 that change, explaining the high plasma from the blood test
(Myśliwiec, 2019). The low levels of erythrocytes from the blood test can be explained
by the disease as well. When functioning properly, the kidneys produce a hormone
called erythropoietin (EPO). The main function of this hormone is to stabilize oxygen
levels and the number of red blood cells in the body, which are the erythrocytes. EPO is
released by the kidneys into the bloodstream when blood oxygen levels are low. It is
then transported to the bone marrow as a stimulus for red blood cell production. In
CKD, there is not enough EPO from dysfunctioning of the kidney and thus red blood
cell levels are below the normal. The kidneys contain nephrons that have filters which
work to return necessary substances and remove waste products. This plays an
important role in regulating protein levels, as the protein waste is removed from the
millions of nephrons, and exists through the urine. In unhealthy kidneys of CKD
patients, the nephrons are not able to remove protein waste and therefore it builds up
in the bloodstream. This makes high levels of protein levels (Davita, 2021).
To ensure my diagnosis for Chronic Kidney Disease is correct, I would order a urine
test from the patient. Through the urine test I would check for the blood protein
Albumin. The protein is needed to grow muscle, repair tissue, and protect from
infection. If the kidney is healthy, the albumin will not be able to pass into the urine.
Having above average levels of albumin in the urine is a sign of Albuminuria.If the
kidney is damaged, the protein has leaked out of the kidneys and went through the
urine. A portion of the urine sample is tested immediately through a dipstick that is
placed in the cup. The other portion of the urine is sent to a laboratory where it
engages in a ACR test, which finds the ratio of Albumin to Creatinine. This is a critical
step in estimating the amount of Albumin that would go through the urine in the span
of 24 hours. A healthy amount of Albumin in the urine is generally 30 mg/g or less. In
the case that there is more than 30 mg/g, the patient is showing signs of CKD. The
diagnosis becomes officially confirmed once a patient tests positive for the albumin
test three times over the course of three months (NKF, 2016). Additionally, measuring
Albumin levels assists the doctor in finding the most beneficial treatment plan for the
patient. The patterns of the urine sample can reveal whether certain treatments are
working or not.
In the majority of CKD cases, there is no way to fully cure the disease but there are
treatment methods that can help manage symptoms and complications. To relieve
cardiovascular and blood pressure complications, I would prescribe the patient with
Angiotensin-converting enzyme inhibitors (ACEis) and angiotensin II receptor blockers
(ARBs). In CKD patients, Angiotensin levels are too elevated, thus the peptide
hormone is overcompensating for narrowing the blood vessels and fluid is building up
in the body. This causes cardiovascular and circulatory complications associated with
CKD including high blood pressure, inflammation in the pericardium membrane and
fluid retention issues. Through the inhibiting medication, Angiotensin I is blocked from
further developing into Angiotensin II. Common examples of ACE medication used in
CKD cases include ramipril, enalapril and lisinopril. The side effects associated with
Angiotensin inhibiting medication include a dry cough, dizziness, and overall weakness.
Through the Angiotensin II receptor blockers, the arteriole in the kidney’s glomerulus
is enlarged, which protects the kidney against toxins and reduces pressure inside the
glomerulus. Common examples of ARBs include Azilsartan, Candesartan, and
Eprosartan. They have all been associated with slowing down progression of chronic
kidney disease. Side effects of the ARB medication can be more severe, such as
elevation of potassium levels leading to hyperkalemia (Mayo Clinic, 2019). In order to
help relieve blood pressure issues, the patient would also have to maintain a diet with
generally low sodium levels (no more than 2,3000 milligrams per day). As the patient’s
kidney damage progresses, they would likely need to be put on anemia medication.
This would include iron supplements and/or injections of erythropoietin, to help the
body increase red blood cell production (NIDDK, 2016).
As the damage of the patient’s kidneys would progress, they would likely develop
anemia in stage 5 of the disease. The main reason for these two conditions being linked
together is the lack of erythropoietin (EPO) that is present in Chronic Kidney disease.
In erythropoietin hormones, the production of red blood cells are maintained and the
synthesis of hemoglobin is initiated. The kidney is the most prominent source for EPO
in the body. This information led to the discovery in the 1950s that EPO deficiency is
the main cause of anemia in patients with CKD, as the production of red blood cells
from EPO relies on healthy kidney function. In anemic patients that don’t have kidney
damage, their EPO levels are 10-100 times higher showing that EPO levels are only
changed when anemic patients have CKD. Other factors that contribute to anemia in
CKD are nutritional deficiencies (e.g folate and vitamin B12 ), and short red blood cell
survival rates from the disease. The nature of anemia in CKD is generally
normochromic, meaning that the blood cells maintain a healthy size but there are too
little to fulfill the body’s needs. Symptoms of normocytic anemia include fatigue and in
more severe cases dizziness. Patients with normocytic anemia can relieve symptoms
by the use of Erythropoietin injections, which help the bone marrow produce larger
numbers of red blood cells (Am Fam Physicians, 2000).
QUESTION 3 - TUBERCULOSIS
Tuberculosis (TB) is a disease that mainly attacks the respiratory system,
specifically the lungs. It is driven from the bacteria known as mycobacterium
tuberculosis. The main source of spread for the disease is through person to person
contact, and is only infectious when located in the lungs. In most cases, people get TB
from other people they see on a regular basis. This disease is carried through droplets,
which get spread into the air when an individual with TB coughs, sneezes, speaks, sings,
etc. As the other individual inhales the bacteria, the bacteria reaches the lungs and
accumulates. If the immune system can’t protect against the TB, the bacteria begins to
multiply making it a disease. It then further attacks the body through destroying tissue.
This becomes very detrimental when in the lungs, as it punctures the structure
creating a hole. In some individuals they become diagnosed with TB a few weeks after
infection, but other individuals will feel the effects of TB years after being infected, due
to their immune system weakening. When a TB infection occurs in the lungs, the
primary symptoms consist of chest pain, a bad cough, and/or haemoptysis. Other
symptoms vary but can include weakness, fatigue, excessive weight loss, lack of
appetite, excessive perspiration, chills, and fever. Nowadays,to get treated for TB,
patients need to endure a 6 month treatment process. They require 4 main antibiotics;
Isoniazid (INH), Rifampin (RIF), Pyrazinamide (PZA), and Ethambutol (EMB). These
drugs remove the contagious factor of TB. If the patient takes their prescribed
medication, attends appointments with their physician, and follows through with the
full regimen then they should be fully treated by the end of the 6 month period (APC,
2021).
Tuberculosis became an epidemic in the 18th century, mainly being located in Western
Europe and Britain. The TB mortality rate of the time consisted of 900 deaths per
100,000 residence on a yearly basis. The disease was known as “the robber of youth”
as it was more prominent among young people. Another group that was highly at risk
for the disease were English workers in the Industrial Revolution. This was driven from
the inadequate work conditions, sanitation, and ventilation systems. Along with this
Malnutrition and overcrowding of houses were factors in the spread of tuberculosis as
well. Workplaces such as factories became sources of the spread. Up to one in three
English employees had a tuberculosis related death, compared to only a sixth of TB
deaths in the upper class (Barberis, 2017). As for Canada, TB became the leading cause
of death in 1867.
Throughout the 18th and early 19th century, there was not a Tuberculosis cure, and
thus doctors could not fully heal patients with severe symptoms and complications.
There were still remedies made to help manage the effects and limit the spread of TB.
One primary example of this was the Sanatoria, a hospital specifically designed for TB
patients. The aim was to allow patients to rest and sustain a proper diet, while
removing them from public places to prevent outbreaks. This was commonly known as
the “rest cure” for TB, and was the main method of treatment before any uses of
antibiotics were introduced. Before 1920 “collapse therapy” was also used. In this
procedure surgeons would pump the chest cavity full with air in order to relax the
lungs and relieve damage caused by TB (CPHA, 2021). In 1943, Selman Waksman was
the first to find the chemical for the first official cure for Tuberculosis. The compound
used in this discovery was the aminoglycoside antibiotic streptomycin, which kills the
organisms that are the origin for the infection.Then in 1948, UNICEF and the Danish
Red Cross worked together on a campaign to control the Tuberculosis outbreaks. The
WHO Organization was the main leader of the campaign, and it was an important
progression in the science community as it was the first disease control campaign.
Their main goal was to complete tuberculin testing as well as testing of the BCG
vaccine. The mission began in Poland but expanded to Europe and other regions of the
world (e.g Ecuador). For the following three years, there were 30 million tuberculin
tested and 14 million injected with the BCG (Daniel, 2006).
Through 1953 to 1984, Tuberculosis cases were declining by a yearly average of 6%
(CDC, 2019). In recent decades, Tuberculosis cases have risen again due to the
resistance that TB has developed to antibiotics. TB medication was being improperly
used, and from this a drug resistant form of the disease was developed. The new strains
have much more dangerous infectious rates. Currently the most common new strain is
TB (MDR-TB), which is problematic as it is resistant to the two most successful anti-TB
drugs. Reports are showing that there are half of a million cases caused by MDR-TB
each year. In the new strains (including TB (MDR-TB)), Tuberculosis is not only
spreading from individuals who tested, but from individuals who have never been
exposed to the disease. This has decreased the effectiveness of standard TB
medications, making doctors have no choice but to rely on expensive treatment
regimes. These treatment regimes are not a fully effective method, as only half of TB
patients get successfully cured. It is also a gruelling process of injections that have to
be taken for 8 months, and have severe complications involved (Levy, 2018). These
factors have contributed to TB becoming one of the most deadly diseases in the world.
In 2018 more than 1.5 million people worldwide died from TB, making it number one in
infection caused deaths (UPMC Infectious Diseases, 2019).
QUESTION 2 - VOMITING AND NAUSEA
Question
Why was it asked?
Hypothetical response
When did the vomiting
begin and how long do
the spells last
If vomiting spells are consistent and
happening through “episodes” throughout a
certain part of the day, it opens the
possibility that the patient could have
cycling vomit syndrome.
Usually I begin to feel nauseous
around 3 each day, and I start
vomiting for a while but then it
goes away until the next day.
The vomiting has been very sparse.
Vomiting that occurs right after eating
would provide proof that the patient is
experiencing acid reflux as a result of
GERD.
As the food reaches the acid it sparks back
up into the esophagus causing nausea.
Yes, I can’t hold my food down and
I start to get burps that make it feel
like it has to come back up after a
meal.
Did other people who
ate the same thing
experience the same
symptoms
This question would reveal if the food was
not prepared safely, and
Contained a harmful pathogen that
provoked a virus. If no one else had
digestion problems after eating the same
meal, it could be signs of food intolerance.
No, I went out to eat with multiple
friends but I’ve been the only one
with any symptoms.
Did you vomit blood or
did the vomit look
black like coffee
grounds
This question is critical for the doctor to
ask, because signs of Hematemisis are
considered a medical emergency. The
patient would need to be sent to the
emergency room immediately to prevent
them reaching hypovolemic shock.
Yes, my vomit has a black or brown
look to it and has a weird
consistency.
If the patient is unintentionally losing mass
amounts of weight combined with
nausea/vomiting, they’re showing signs of
Hyperthyroidism. If they lose around 3
pounds from throwing up, that is not a clear
Yes, I lost 4 pounds after a few
days of a lot of vomiting.
Does it occur right
after meals
Have you lost weight
since this started
Yes, we have all been unable to
leave the house because
everyone's vomiting.
Yes, my vomit looks bright red.
Yes, since two weeks ago I’ve lost
25 pounds even though I have a big
Have you been
traveling recently
What medications do
you currently take
sign of having hyperthyroidism.
appetite and eat often.
It is very common for someone to get a virus
after traveling. Parasites are usually spread
through contaminated water or infectious
people, which are very easy to encounter
while traveling.
Yes, my family travelled to Mexico.
We stayed at a resort with lots of
people, and went out to eat at
restaurants a lot.
Nausea and vomiting are common side
effects for a variety of medications.
I am currently on antidepressants
and fenoprofen medication.
Cycling Vomit Syndrome describes the repeating episodes of severe nausea and
vomiting. This can take place multiple times in the span of an hour, and episodes are
able to last from a number of hours to days, depending on the severity of the disease.
The effects are very consistent as vomiting attacks tend to repeat at the same time of
day, have the duration, and have the same intensity of symptoms. The disorder
involves 4 main phases. In the first phase (prodrome phase), an individual will
anticipate the episode from symptoms such as intense sweating and nausea, lasting
from a few minutes to several hours. Then they enter the vomiting phase. This can
make them unable to respond to others around them or move, while enduring intense
pain in their abdomen. After the vomiting ends, they enter the recovery phase which
allows them to slowly gain back their skin colour, appetite, and energy. Between
episodes they experience the recovery phase, in which there are no symptoms. To
prevent episodes from reoccurring, most doctors will prescribe over the counter
medication. For example, Famotidine or ranitidine is used to control acid levels,
ondansetron is used to relieve nausea, and sumatriptan to relieve migraines. It is also
recommended that patients with CVS take measures to prevent triggers to nausea,
such as treating infections or allergies, receiving enough sleep, managing anxiety, and
avoiding foods that induce episodes (Venkatesan, ).
Gastroesophageal reflux disease (GERD) is a condition that occurs when stomach acid
regurgitates in the esophagus. The condition is also related to acid reflux, as a patient
that has acid reflux more than two times a week will receive a diagnosis for GERD. This
causes loss of function abilities for the gastroesophageal sphincter, the valve that
regulates movement between the esophagus and the stomach. The most noticeable
symptom is heartburn, but patients with the condition can also experience nausea and
vomiting as well. In most GERD patients, the symptoms start to arise immediately after
eating (Fernado del Rosario, 2015). Risk of getting GERD is increased in those who are
obese, pregnant, on certain medications (e.g asthma, calcium channel inhibbitors,
antihistamines, sedatives, etc.), smokers, or been in close contact with secondhand
smoke. If untreated, GERD can lead to narrowing or inflammation of the esophagus,
along with respiratory problems. The condition is mainly treated with pharmaceuticals,
such as proton pump inhibitors to decrease the quantity of acid produced in the
stomach. Other commonly used medications include H2 blockers and Antacids used
for stomach acid, along with Prokinetics and Erythromycin to help empty the stomach
at faster rates (Choi, 2018).
In foodborne illnesses (commonly known as food poisoning), an individual has ingested
food containing organisms that have developed harmful pathogens including bacteria,
viruses, or parasites. In the US, the most common foodborne illnesses include
salmonella, norovirus, E. Coli, Campylobacter, Clostridium perfringens, and Listeria.
Symptoms of those foodborne illnesses can include nausea, diarrhea, vomiting,
abdominal cramps, weakness, and fever. Considering the patient’s symptoms, it is most
likely that they ingested a food containing activity of norovirus. This bacteria comes as
a result from raw produce, non potable water, shellfish from toxic waters, and foods
that have been handled by an infected person (FDA, 2018).
Food intolerances only occur in the digestive tract, which makes their symptoms
sufficiently less severe than in food allergies (which come as an immunological
response to certain substances). An individual with a food intolerance has difficulty
digesting food that results in gastrointestinal symptoms (VLS, 2021). If the patient is
experiencing nausea and vomiting after eating, they most likely have lactose
intolerance. This occurs when the small intestine doesn’t have the necessary amount of
lactase enzymes to digest lactose, forcing the lactose to move to the colon (therefore it
does not get processed or absorbed). This causes symptoms such as nausea, diarrhea,
and vomiting. These start to arise thirty minutes to two hours after ingestion of foods
containing lactose. Assuming that the symptoms are relativity new, the patient has
primary lactose. This means that as an infant they did produce the needed amount of
lactase, but as they entered adulthood their lactase levels dropped immensely. The
main method of treatment for lactose intolerance is a low lactose diet. Therefore
patients have to limit or completely remove dairy products (e.g milk, icecream, etc). An
alternative to this is to take over the counter lactase enzyme tablets or drops before
eating food containing lactose (Mayo Clinic, 2020).
If a person is experiencing Hematemisis, it likely means that they have a bleeding ulcer.
The ulcers are open sores that have developed in the digestive system. There are two
main divisions of ulcers; gastric ulcers that are located inside the stomach, and
duodenal ulcers which are located in the upper section of the small intestine. These
appear when there is too much acid or not enough mucus which destroys the
protective layer of the gut lining. This makes the acid wear at the organ’s surface,
resulting in an open sore. If the patient is vomiting blood or a dark substance, it means
that their ulcer is bleeding and they are experiencing a hemorrhage. These become
fatal when a person loses 30% or more of their blood within a short period of time.
Bleeding ulcers require emergency surgery to fully close the hemorrhaging ulcer. The
surgeon identifies the bleeding source by locating a small artery on the ulcer, and then
stops the bleeding (WebMD, 2021). Patients with duodenal ulcers are required to stay
on a liquid diet for up to a month in order to heal their internal wound. After patients
have recovered from a bleeding ulcer, they are advised to have an endoscopy done on
a later date as a confirmation that there are not any ulcers and that the body has fully
recovered (Weatherspoon, 2019).
Hyperthyroidism is the overactivation of the thyroxine hormone produced in the
thyroid gland, which over elevates the body’s metabolic rate. There are three main
causes for hyperthyroidism. These include grave disease (the thyroid acts as a
stimulant for immune system attacks), nodules on the thyroid (increasing tissue size),
and arrhythmia medications. The most prominent symptoms are increased
unintentional weight loss, arrhythmias, and heart palpitations (Mayo Clinic, 2020).
Other symptoms include nausea, vomiting, frequent bowel movements, heat
intolerance, and increased appetite. To treat hyperthyroidism, antithyroid medications
are prescribed to inhibit the excess thyroid hormones. Radioactive iodine can be used
to destroy the thyroid gland and stop hormone production as well. There is also an
option to surgically remove the thyroid gland completely. The choice for treatment
varies depending on the cause and severity of the complications (Wisse, 2018). If the
patient is experiencing nausea and vomiting as a result of other medications they are
taking, there is not a specific diagnosis to a condition that can be provided. They can
find the root of cause, which is most likely an antibiotic. These include Erythrocin,
NSAIDs, ibuprofen, naproxen, Nifedical, and Procardia. Non antibiotic medications
that induce nausea and vomiting include antidepressants, and chemotherapy drugs.
The main reason for the side effect is the way that the medication targets the problem
in the body. For instance, NSAIDs reduce inflammation by targeting the stomach lining,
which acts as a stimulant for nausea and vomiting. Nausea also happens as a result of
medication staying in the stomach for too long. As we age our ability to absorb
medication decreases, making the absorption process longer. This makes doctors
sometimes bring up not taking the medication with certain foods, and it recommended
to take medication with lighter foods as opposed to fattier foods. If the nausea persists,
the doctor may reduce the dosage of the medication, introduce another drug to block
nausea, or in some cases remove the medication completely (Harvard Health, 2019).
Viral Gastroenteritis (more commonly known as the Stomach flu) is an infection of the
intestines. It causes Nausea, vomiting, watery diarrhea, abdominal cramps, low grade
fever and occasional muscle pain or migraines. In most cases symptoms persist for 1 to
4 days. The bacteria that spreads the infection is the Rotavirus, which commonly gets
spread when children put their fingers that have been in contact with the virus in their
mouth. Transmission of the virus is very frequent when travelling, either from close
contact with infected people or contaminated food/water. That’s why health
practitioners highly recommend avoiding drinking tap water (whether when brushing
teeth, in ice cubes of drinks, when showering, etc.) and eating raw food that has been
handled to reduce the chances of catching it. There is not a specific medication that can
be used to cure symptoms. Antibiotics can not fully fight off the virus, and overusing
them leads to bacteria with antibiotic resistant strains. There still are remedies that
can lessen the effects of symptoms, such as getting rest, taking in more electrolytes,
and staying hydrated (Mayo Clinic, 2018).
QUESTION 4 - BMI
Body Mass Index (BMI) is a formula that takes into account the weight and
height of a person to determine the amount of fat on their body. For over 100 years
medical practitioners have been using it as a reference for if a patient is underweight
or overweight. According to the BMI scale, Yasmin technically has an overweight BMI
because she falls under the 25-29 overweight category. With Yasmin's physical
activity rates, it is likely that her BMI count is not an accurate representation of her
health. In recent years, the BMI scale has been criticized by medical professionals as it
does not take into account other parts that make up one’s weight such as muscle mass.
If we look at all the combinations for someone with a BMI of 27, there is a huge variety
in her weight to height ratio. Yasmin could be anywhere from 4’8 ft with a weight of
120 lbs, 5’10 with a weight of 190 lbs, to 6’11 with a weight of 260 lbs (BMI Calculator
Canada, 2020). This isn’t including the other combinations in between the ones listed.
An argument used by health professionals against the BMI system is that it’s
oversimplified. The BMI system was developed in the 1830s, and medical technology
has progressed so much since then. People also were built differently in the 1800s.
Malnutrition was much more common in England during that time, so their depiction of
a healthy weight came from a different perspective. Nowadays, there are Olympic
athletes that have much higher muscle mass but lower body fat than the average
person. Compared to someone living in the 1800s, it is fair to assume that they are
much healthier but the BMI system may disagree with that. Muscle weighs around 18%
more than fat, and if a person were to develop 10% of their fat into muscle their BMI
would still increase. In the BMI scale more muscle can make you clinically obese, even
if you’re more fit than the average person. I think this is the case in Yasmin’s BMI. It is
most likely that she has high percentages of muscle (from training as an elite athlete),
and is over 5’6” which are both high factors in her weight. The bigger determining
factor in her health is her fat percentage, and as long as it is not above 14 she is not
clinicially obese (Bubnis, Daniel).
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