SlideShare a Scribd company logo
1 of 63
5/10/2019 1Tuberculosis
TUBERCULOSIS
PRESENTED BY:
Ms. Ann Joseph
M.Sc. Nursing I year
5/10/2019 Tuberculosis 2
5/10/2019 3Tuberculosis
OBJECTIVES
• Define tuberculosis
• Explain the risk factors and causes of tuberculosis
• Describe the pathophysiology of tuberculosis.
• Identify the types of tuberculosis.
• Enumerate clinical features of tuberculosis
5/10/2019 4Tuberculosis
• Describe the diagnostic evaluations for tuberculosis
• Explain the medical management for tuberculosis
• Explain the nursing management for tuberculosis
• Enlist the complications of tuberculosis
• Describe the prevention of tuberculosis
5/10/2019 5Tuberculosis
ANATOMY
AND
PHYSIOLOGY
5/10/2019 Tuberculosis 6
5/10/2019 Tuberculosis 7
5/10/2019 Tuberculosis 8
5/10/2019 9Tuberculosis
5/10/2019 10Tuberculosis
DEFINITION
Tuberculosis is a chronic
infectious disease that is
characterized by the
formation of tubercles or
granulomas in the lungs.
5/10/2019 11Tuberculosis
GRANULOMAS
5/10/2019 Tuberculosis 12
INCIDENCE
• 3 million new cases are
diagnosed each year.
• In India it accounts for 60% of
total cases worldwide
• 4,80,000-50,00,000 People loses
their life.
• It kills 5000 people daily.
5/10/2019 Tuberculosis 13
RISK FACTORS
5/10/2019 Tuberculosis 14
ETIOLOGY
• Mycobacterium tuberculosis
Discovered by Robert Koch
Aerobic , non motile , rod shaped organism.
5/10/2019 Tuberculosis 15
PATHOPHYSIOLOGY
5/10/2019 16Tuberculosis
Due to etiological factors
Exposure or inhalation of infected aerosol through droplet nuclei
Tuberculosis bacilli invasion in the apex of the lungs or near the pleurae
of the lower lobe
Bronchopneumonia develops in lung tissues as phagocytosed tubercle
bacilli are ingested by macrophages.
Necrotic degeneration occurs i.e, production of cavities filled with
cheese like mass of tubercle bacilli, dead WBC’s , necrotic lung tissue
Drainage of necrotic material into tracheobronchial tree5/10/2019 17
Tuberculosis
Lesions may calcify (ghon’s complex) and may form scar
Tubercle bacilli immunity develops
Acquired immunity leads to further growth of bacilli and
development of active infection
Sign and symptoms
5/10/2019 18Tuberculosis
Sign and symptoms
Medical interventions without medical intervention
• TB DOTS , BCG vaccination reactivation of tubercle
bacilli
Non recurrence Recurrence secondary infection
Good prognosis Bad prognosis
5/10/2019 Tuberculosis 19
Secondary infection
Severe occurrence of lesions in lungs
Cavitations in lungs
Active infection spread throughout body system
Severe infection
5/10/2019 Tuberculosis 20
CLASSIFICATION
5/10/2019 Tuberculosis 21
5/10/2019 Tuberculosis 22
TYPES OF
TUBERCULOSIS
5/10/2019 Tuberculosis 23
CLINICAL MANIFESTATION
5/10/2019 Tuberculosis 24
CLINICAL MANIFESTATION CONT.
5/10/2019 Tuberculosis 25
PRODUCTIVE/ NON PRODUCTIVE COUGH
CLINICAL MANIFESTATION CONT.
5/10/2019 Tuberculosis 26
SUDDEN WEIGHT LOSS
CLINICAL MANIFESTATION CONT.
5/10/2019 Tuberculosis 27
LOSS OF APPETITE
CLINICAL MANIFESTATION CONT.
FEVER
5/10/2019 Tuberculosis 28
CLINICAL MANIFESTATION CONT.
NIGHT SWEATS
5/10/2019 Tuberculosis 29
CLINICAL MANIFESTATION CONT.
HEMOPTYSIS
5/10/2019 Tuberculosis 30
CLINICAL MANIFESTATION CONT.
CHEST PAIN AND CHEST TIGHTNESS
5/10/2019 Tuberculosis 31
CLINICAL MANIFESTATION CONT.
FATIGUE
5/10/2019 Tuberculosis 32
DIAGNOSTIC EVALUATION
5/10/2019 Tuberculosis 33
DIAGNOSTIC EVALUATION
• Health history
• Physical examination
• Bacteriological studies
5/10/2019 Tuberculosis 34
5/10/2019 Tuberculosis 35
SPUTUM TEST
CHEST X RAY
5/10/2019 Tuberculosis 36
TUBERCULIN SKIN TEST
• Mantoux test
• 0.1 ml of PPD (Protein purified
derivative)
• Creates a well marked wheal (6-
10mm)
• Result read out in 48-72 hours.
5/10/2019 Tuberculosis 37
TUBERCULIN SKIN TEST CONT.
• Reaction occurs when both
induration and redness are
present.
• 5mm or greater are at risk/
positive.
5/10/2019 Tuberculosis 38
MANAGEMENT
5/10/2019 Tuberculosis 39
PHARMACOLOGICAL
MANAGEMENT
DOTS
Direct Observed Treatment Schedule.
Antibiotics combination is given for 6 months
ISONIAZIDE (H) + RIFAMPICIN(R) + PYRAZINAMIDE (Z) +
ETHAMBUTOL (E)
5/10/2019 40Tuberculosis
DOTS treatment regiment
5/10/2019 Tuberculosis 41
RECOMMENDED DOSAGE
DRUGS DAILY DOSE THRICE/ WEEK
DOSE
Isoniazide (H) 5mg/kg, max 300mg 10mg/kg, max 900mg
Rifampicin (R) 10mg/kg, max 600mg 10mg/kg, max 600mg
Pyrazinamide (Z) 25mg/kg, max 2gm 35mg/kg, max 3gm
Ethambutol (E) 15mg/kg 30mg/kg
5/10/2019 42Tuberculosis
MEDICATION RESISTANCE
Primary resistance occurs when infected with resistant strain of TB.
Secondary resistance is acquired during inadequate treatment,
inappropriate regimen , low quality medications leading to DRUG
RESISTANT TB.
TAB. BEDAQUILINE is used for drug resistant TB.
Dose :400mg once a day or300mg thrice per week.
5/10/2019 43Tuberculosis
NURSING MANAGEMENT
Nurses play an important role in prevention and treatment of TB.
 Monitor patient.
 Educate patient on the importance of treatment and drug therapy.
 Ensure medication consumption at right time.
 Educate patient about measures to be taken to prevent the spread of
infection.
5/10/2019 44Tuberculosis
NURSING MANAGEMENT CONT.
 Educate the importance of medication and
side effects if not taken properly.
 Explain all the complications.
 Educate patient regarding nutrition
specifically about protein rich diet.
5/10/2019 Tuberculosis 45
NURSING DIAGNOSIS
1. Ineffective airway clearance related to excessive secretions as
evidenced by ineffective cough.
2. Ineffective breathing pattern related to pain as evidenced by shallow
respiration.
3. Imbalanced nutrition less than body requirement related to anorexia
as evidenced by weight loss.
4. Activity intolerance related to imbalance between oxygen demand
and supply as evidenced by dyspnea.
5. Knowledge defecit related to lack of exposure as evidenced by
frequent questioning of patient.
5/10/2019 46Tuberculosis
COMPLICATIONS
1) Meningitis
2) Pott’s disease
3) Hemoptysis
4) Empyema
5) Pneumothorax
6) Bronchiectasis
7) Laryngitis
5/10/2019 47Tuberculosis
PREVENTION
5/10/2019 48Tuberculosis
BCG VACCINATION
BACILLUS CALMETTE GUERIN
•Developed in 1921.
•Given immediately after birth or within 1 year of birth.
5/10/2019 49Tuberculosis
COUGH ETTIQUETTES
5/10/2019 50Tuberculosis
5/10/2019 Tuberculosis 51
REVISED NATIONAL TUBERCULOSIS
CONTROL PROGRAMME
To eliminate TB from India a new strategic plan is developed that is
‘NATIONAL STRATEGIC PLAN FOR TUBERCULOSIS
ELIMINATION 2017-2025’
This plan has been integrated on 4 pillars of
DETECT, TREAT, PREVENT, BUILD
 To facilitate TB notification RNTCP has developed “NIKSHAY”.
5/10/2019 52Tuberculosis
5/10/2019 Tuberculosis 53
NIKSHAYA POSHAK YOJANA
• In this scheme financial incentive of rs.500 is given per month for
nutritional support to each notified TB cases.
•It is directly transferred to bank account of the beneficiary through
direct benefit transfer.
5/10/2019 54Tuberculosis
5/10/2019 55Tuberculosis
TREATMENT OUTCOME AMONG CASES OF
MDR TB IN WESTERN INDIA
Sangita P, Kapil, Alpesh, lipy, Kalpita, kedar and Joshi
A prospective cohort study was carried out by enrolling all the
registered patients in DOTs Plus centre of Vadodara district from
February 2015 to December 2015 to determine the treatment outcome
in patients with MDR TB in seven districts and to examine the factors
affecting the treatment outcome.
5/10/2019 Tuberculosis 56
• A total of 145 patients were interviewed using a pre-tested semi-
structured questionnaire at the DOTS centres.
• After 24 months, of those 145 patients, 48 (33.10%) were declared
cured, 8 (5.50%) had completed their treatment, 43 (29.70%) patients
died during the treatment, and 32 (21.10%) patients defaulted during
treatment.
5/10/2019 Tuberculosis 57
• Factors associated with a significant difference in the outcomes were
income, marital status, and education.
• Study concluded that proper counselling on drug adherence should be
applied at the programmatic level.
5/10/2019 Tuberculosis 58
RECAPITUALATION
• Define tuberculosis?
• Explain the risk factors and causes of tuberculosis?
• Describe the pathophysiology of tuberculosis?
• Identify the types of tuberculosis?
• Enumerate clinical features of tuberculosis?
• Describe the diagnostic evaluations for tuberculosis?
• Explain the management for tuberculosis?
• Enlist the complications of tuberculosis?
• Describe the prevention of tuberculosis ?
5/10/2019 Tuberculosis 59
DOUBTS??
5/10/2019 Tuberculosis 60
ASSIGNMENT
5/10/2019 Tuberculosis 61
Write an assignment on DOTS regiment
•Total marks:10
•Content:8
•Presentation:2
•Date of submission:13/5/19
• Lewis S L, Bucher L, Dirksen SR, Heitkemper MM. Lewis Medical
Surgical Nursing.2nd ed. New Delhi.Elsevier.2014.
• Smeltzer SC, Hinkle JL, Bare BG, Cheever KH.Brunner and Suddarths
Textbook of Medical Surgical Nursing.12th ed. New Delhi:
Lippincott.2011.
• Black JM, Jacobs EM.Medical Surgical Nursing:Clinical Management
for Continuity of care .5th ed.New Delhi.Jaypee publishers:2000.
• Sandra MN. Lippincott manual of nursing practice.10edition. New
delhi. Wolter kluwer publication.2014
5/10/2019 62MYOCARDIAL INFARCTION
5/10/2019 63Tuberculosis

More Related Content

What's hot (20)

Pulmonary Tuberculosis Presentation
Pulmonary Tuberculosis PresentationPulmonary Tuberculosis Presentation
Pulmonary Tuberculosis Presentation
 
Tuberculosis
TuberculosisTuberculosis
Tuberculosis
 
Tuberculosis
TuberculosisTuberculosis
Tuberculosis
 
Mumps ppt biju
Mumps ppt bijuMumps ppt biju
Mumps ppt biju
 
Tuberculosis
TuberculosisTuberculosis
Tuberculosis
 
PNEUMONIA.pptx
PNEUMONIA.pptxPNEUMONIA.pptx
PNEUMONIA.pptx
 
Tuberculosis
Tuberculosis Tuberculosis
Tuberculosis
 
bacterial pneumonia
bacterial pneumoniabacterial pneumonia
bacterial pneumonia
 
Influenza
InfluenzaInfluenza
Influenza
 
Tb seminar by rs
Tb seminar by rsTb seminar by rs
Tb seminar by rs
 
Pertussis (whooping cough)
Pertussis (whooping cough)Pertussis (whooping cough)
Pertussis (whooping cough)
 
Influenza
Influenza Influenza
Influenza
 
Tuberculosis TB
Tuberculosis TBTuberculosis TB
Tuberculosis TB
 
Pneumonia
PneumoniaPneumonia
Pneumonia
 
Pneumonia
PneumoniaPneumonia
Pneumonia
 
Tuberculosis seminar.
Tuberculosis seminar.Tuberculosis seminar.
Tuberculosis seminar.
 
Tuberculosis slides
Tuberculosis slidesTuberculosis slides
Tuberculosis slides
 
Pulmonary tuberculosis..ptt
Pulmonary tuberculosis..pttPulmonary tuberculosis..ptt
Pulmonary tuberculosis..ptt
 
Tuberculosis
Tuberculosis Tuberculosis
Tuberculosis
 
GEMC- Typhoid Fever, Infectious Diarrhea, Diphtheria, and Pertussis- for Nurses
GEMC- Typhoid Fever, Infectious Diarrhea, Diphtheria, and Pertussis- for NursesGEMC- Typhoid Fever, Infectious Diarrhea, Diphtheria, and Pertussis- for Nurses
GEMC- Typhoid Fever, Infectious Diarrhea, Diphtheria, and Pertussis- for Nurses
 

Similar to Tb TUBERCULOSIS

Pulmonary tuberculosis
Pulmonary tuberculosisPulmonary tuberculosis
Pulmonary tuberculosisMahesh Chand
 
Antibacterial therapy in COVID-19 patients - an evidence based guideline
Antibacterial therapy in COVID-19  patients - an evidence based guidelineAntibacterial therapy in COVID-19  patients - an evidence based guideline
Antibacterial therapy in COVID-19 patients - an evidence based guidelineDr Jay Prakash
 
Rational use of antibiotics ppt -Dr AVINASH KUMAR SENIOR RESIDENT DM NEUROLO...
Rational use of antibiotics  ppt -Dr AVINASH KUMAR SENIOR RESIDENT DM NEUROLO...Rational use of antibiotics  ppt -Dr AVINASH KUMAR SENIOR RESIDENT DM NEUROLO...
Rational use of antibiotics ppt -Dr AVINASH KUMAR SENIOR RESIDENT DM NEUROLO...DrAvinash Kumar
 
Managment Of Long Term Care In Era Covid-19
Managment Of Long Term Care In Era Covid-19Managment Of Long Term Care In Era Covid-19
Managment Of Long Term Care In Era Covid-19komalicarol
 
2250-Presentation+III-LindaMeAHand
2250-Presentation+III-LindaMeAHand2250-Presentation+III-LindaMeAHand
2250-Presentation+III-LindaMeAHandJennifer Vo
 
COVID-19 &Tuberculosis What is The Link?
COVID-19 &Tuberculosis  What is The Link?COVID-19 &Tuberculosis  What is The Link?
COVID-19 &Tuberculosis What is The Link?Ashraf ElAdawy
 
The prevalence and treatment of tuberculosis (TB) in primary health care sett...
The prevalence and treatment of tuberculosis (TB) in primary health care sett...The prevalence and treatment of tuberculosis (TB) in primary health care sett...
The prevalence and treatment of tuberculosis (TB) in primary health care sett...SriramNagarajan17
 
PRIMARY LEVEL CARE OF TUBERCULOSIS
PRIMARY LEVEL CARE OF TUBERCULOSISPRIMARY LEVEL CARE OF TUBERCULOSIS
PRIMARY LEVEL CARE OF TUBERCULOSISKeagan Kirugo
 
WORLD TUBERCULOSIS DAY MARCH 24 2021.pptx
WORLD TUBERCULOSIS DAY MARCH 24 2021.pptxWORLD TUBERCULOSIS DAY MARCH 24 2021.pptx
WORLD TUBERCULOSIS DAY MARCH 24 2021.pptxanjalatchi
 
Suggestion of the university students about the cause of prostatitis and thei...
Suggestion of the university students about the cause of prostatitis and thei...Suggestion of the university students about the cause of prostatitis and thei...
Suggestion of the university students about the cause of prostatitis and thei...BRNSSPublicationHubI
 
Pulmonary infections annually rank among the top causes of death in th.docx
Pulmonary infections annually rank among the top causes of death in th.docxPulmonary infections annually rank among the top causes of death in th.docx
Pulmonary infections annually rank among the top causes of death in th.docxsharold2
 
Psychological Status of Medical Post Graduates During Covid19 in Northern Ind...
Psychological Status of Medical Post Graduates During Covid19 in Northern Ind...Psychological Status of Medical Post Graduates During Covid19 in Northern Ind...
Psychological Status of Medical Post Graduates During Covid19 in Northern Ind...DrHeena tiwari
 
Restart fertility in Covid19: Indian Perspective and International Guidance
Restart fertility in Covid19: Indian Perspective and International GuidanceRestart fertility in Covid19: Indian Perspective and International Guidance
Restart fertility in Covid19: Indian Perspective and International GuidanceShivani Sachdev
 

Similar to Tb TUBERCULOSIS (20)

Pulmonary tuberculosis
Pulmonary tuberculosisPulmonary tuberculosis
Pulmonary tuberculosis
 
Tuberculosis
TuberculosisTuberculosis
Tuberculosis
 
final thesis
final thesisfinal thesis
final thesis
 
Epidemiology of infections and quality concepts by Dr.T.V.Rao MD ...
Epidemiology of infections and quality concepts     by Dr.T.V.Rao MD         ...Epidemiology of infections and quality concepts     by Dr.T.V.Rao MD         ...
Epidemiology of infections and quality concepts by Dr.T.V.Rao MD ...
 
Antibacterial therapy in COVID-19 patients - an evidence based guideline
Antibacterial therapy in COVID-19  patients - an evidence based guidelineAntibacterial therapy in COVID-19  patients - an evidence based guideline
Antibacterial therapy in COVID-19 patients - an evidence based guideline
 
Rational use of antibiotics ppt -Dr AVINASH KUMAR SENIOR RESIDENT DM NEUROLO...
Rational use of antibiotics  ppt -Dr AVINASH KUMAR SENIOR RESIDENT DM NEUROLO...Rational use of antibiotics  ppt -Dr AVINASH KUMAR SENIOR RESIDENT DM NEUROLO...
Rational use of antibiotics ppt -Dr AVINASH KUMAR SENIOR RESIDENT DM NEUROLO...
 
Managment Of Long Term Care In Era Covid-19
Managment Of Long Term Care In Era Covid-19Managment Of Long Term Care In Era Covid-19
Managment Of Long Term Care In Era Covid-19
 
2250-Presentation+III-LindaMeAHand
2250-Presentation+III-LindaMeAHand2250-Presentation+III-LindaMeAHand
2250-Presentation+III-LindaMeAHand
 
COVID-19 &Tuberculosis What is The Link?
COVID-19 &Tuberculosis  What is The Link?COVID-19 &Tuberculosis  What is The Link?
COVID-19 &Tuberculosis What is The Link?
 
The prevalence and treatment of tuberculosis (TB) in primary health care sett...
The prevalence and treatment of tuberculosis (TB) in primary health care sett...The prevalence and treatment of tuberculosis (TB) in primary health care sett...
The prevalence and treatment of tuberculosis (TB) in primary health care sett...
 
PRIMARY LEVEL CARE OF TUBERCULOSIS
PRIMARY LEVEL CARE OF TUBERCULOSISPRIMARY LEVEL CARE OF TUBERCULOSIS
PRIMARY LEVEL CARE OF TUBERCULOSIS
 
WORLD TUBERCULOSIS DAY MARCH 24 2021.pptx
WORLD TUBERCULOSIS DAY MARCH 24 2021.pptxWORLD TUBERCULOSIS DAY MARCH 24 2021.pptx
WORLD TUBERCULOSIS DAY MARCH 24 2021.pptx
 
Suggestion of the university students about the cause of prostatitis and thei...
Suggestion of the university students about the cause of prostatitis and thei...Suggestion of the university students about the cause of prostatitis and thei...
Suggestion of the university students about the cause of prostatitis and thei...
 
TB recurrence in Abbottabad.pptx
TB recurrence in Abbottabad.pptxTB recurrence in Abbottabad.pptx
TB recurrence in Abbottabad.pptx
 
Epidemiology of TB
Epidemiology of TBEpidemiology of TB
Epidemiology of TB
 
NTEP and recent advances.pptx
NTEP and recent advances.pptxNTEP and recent advances.pptx
NTEP and recent advances.pptx
 
Pulmonary infections annually rank among the top causes of death in th.docx
Pulmonary infections annually rank among the top causes of death in th.docxPulmonary infections annually rank among the top causes of death in th.docx
Pulmonary infections annually rank among the top causes of death in th.docx
 
Communicable Diseases
Communicable DiseasesCommunicable Diseases
Communicable Diseases
 
Psychological Status of Medical Post Graduates During Covid19 in Northern Ind...
Psychological Status of Medical Post Graduates During Covid19 in Northern Ind...Psychological Status of Medical Post Graduates During Covid19 in Northern Ind...
Psychological Status of Medical Post Graduates During Covid19 in Northern Ind...
 
Restart fertility in Covid19: Indian Perspective and International Guidance
Restart fertility in Covid19: Indian Perspective and International GuidanceRestart fertility in Covid19: Indian Perspective and International Guidance
Restart fertility in Covid19: Indian Perspective and International Guidance
 

More from Ann Joseph

Angina pectoris
Angina pectorisAngina pectoris
Angina pectorisAnn Joseph
 
Acyanotic heart disease
Acyanotic heart diseaseAcyanotic heart disease
Acyanotic heart diseaseAnn Joseph
 
Diabetes insipidus
Diabetes insipidusDiabetes insipidus
Diabetes insipidusAnn Joseph
 
Pyloric stenosis
Pyloric stenosisPyloric stenosis
Pyloric stenosisAnn Joseph
 
Notice flannel
Notice flannelNotice flannel
Notice flannelAnn Joseph
 
Group discussion
Group discussionGroup discussion
Group discussionAnn Joseph
 
Group discussion
Group discussionGroup discussion
Group discussionAnn Joseph
 
Quality Assurance in nursing
Quality Assurance in nursingQuality Assurance in nursing
Quality Assurance in nursingAnn Joseph
 

More from Ann Joseph (10)

Angina pectoris
Angina pectorisAngina pectoris
Angina pectoris
 
Acyanotic heart disease
Acyanotic heart diseaseAcyanotic heart disease
Acyanotic heart disease
 
Diabetes insipidus
Diabetes insipidusDiabetes insipidus
Diabetes insipidus
 
Pyloric stenosis
Pyloric stenosisPyloric stenosis
Pyloric stenosis
 
Notice flannel
Notice flannelNotice flannel
Notice flannel
 
Demonstration
DemonstrationDemonstration
Demonstration
 
Question bank
Question bankQuestion bank
Question bank
 
Group discussion
Group discussionGroup discussion
Group discussion
 
Group discussion
Group discussionGroup discussion
Group discussion
 
Quality Assurance in nursing
Quality Assurance in nursingQuality Assurance in nursing
Quality Assurance in nursing
 

Recently uploaded

PNEUMOTHORAX AND ITS MANAGEMENTS.pdf
PNEUMOTHORAX   AND  ITS  MANAGEMENTS.pdfPNEUMOTHORAX   AND  ITS  MANAGEMENTS.pdf
PNEUMOTHORAX AND ITS MANAGEMENTS.pdfDolisha Warbi
 
Case Report Peripartum Cardiomyopathy.pptx
Case Report Peripartum Cardiomyopathy.pptxCase Report Peripartum Cardiomyopathy.pptx
Case Report Peripartum Cardiomyopathy.pptxNiranjan Chavan
 
Measurement of Radiation and Dosimetric Procedure.pptx
Measurement of Radiation and Dosimetric Procedure.pptxMeasurement of Radiation and Dosimetric Procedure.pptx
Measurement of Radiation and Dosimetric Procedure.pptxDr. Dheeraj Kumar
 
Report Back from SGO: What’s New in Uterine Cancer?.pptx
Report Back from SGO: What’s New in Uterine Cancer?.pptxReport Back from SGO: What’s New in Uterine Cancer?.pptx
Report Back from SGO: What’s New in Uterine Cancer?.pptxbkling
 
Informed Consent Empowering Healthcare Decision-Making.pptx
Informed Consent Empowering Healthcare Decision-Making.pptxInformed Consent Empowering Healthcare Decision-Making.pptx
Informed Consent Empowering Healthcare Decision-Making.pptxSasikiranMarri
 
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment BookingCall Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment BookingNehru place Escorts
 
Apiculture Chapter 1. Introduction 2.ppt
Apiculture Chapter 1. Introduction 2.pptApiculture Chapter 1. Introduction 2.ppt
Apiculture Chapter 1. Introduction 2.pptkedirjemalharun
 
Glomerular Filtration and determinants of glomerular filtration .pptx
Glomerular Filtration and  determinants of glomerular filtration .pptxGlomerular Filtration and  determinants of glomerular filtration .pptx
Glomerular Filtration and determinants of glomerular filtration .pptxDr.Nusrat Tariq
 
COVID-19 (NOVEL CORONA VIRUS DISEASE PANDEMIC ).pptx
COVID-19  (NOVEL CORONA  VIRUS DISEASE PANDEMIC ).pptxCOVID-19  (NOVEL CORONA  VIRUS DISEASE PANDEMIC ).pptx
COVID-19 (NOVEL CORONA VIRUS DISEASE PANDEMIC ).pptxBibekananda shah
 
Primary headache and facial pain. (2024)
Primary headache and facial pain. (2024)Primary headache and facial pain. (2024)
Primary headache and facial pain. (2024)Mohamed Rizk Khodair
 
Glomerular Filtration rate and its determinants.pptx
Glomerular Filtration rate and its determinants.pptxGlomerular Filtration rate and its determinants.pptx
Glomerular Filtration rate and its determinants.pptxDr.Nusrat Tariq
 
Call Girls Viman Nagar 7001305949 All Area Service COD available Any Time
Call Girls Viman Nagar 7001305949 All Area Service COD available Any TimeCall Girls Viman Nagar 7001305949 All Area Service COD available Any Time
Call Girls Viman Nagar 7001305949 All Area Service COD available Any Timevijaych2041
 
Statistical modeling in pharmaceutical research and development.
Statistical modeling in pharmaceutical research and development.Statistical modeling in pharmaceutical research and development.
Statistical modeling in pharmaceutical research and development.ANJALI
 
call girls in dwarka DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in dwarka DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️call girls in dwarka DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in dwarka DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️saminamagar
 
call girls in green park DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in green park  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️call girls in green park  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in green park DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️saminamagar
 
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...rajnisinghkjn
 
Hematology and Immunology - Leukocytes Functions
Hematology and Immunology - Leukocytes FunctionsHematology and Immunology - Leukocytes Functions
Hematology and Immunology - Leukocytes FunctionsMedicoseAcademics
 
call girls in paharganj DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in paharganj DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️call girls in paharganj DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in paharganj DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️saminamagar
 
See the 2,456 pharmacies on the National E-Pharmacy Platform
See the 2,456 pharmacies on the National E-Pharmacy PlatformSee the 2,456 pharmacies on the National E-Pharmacy Platform
See the 2,456 pharmacies on the National E-Pharmacy PlatformKweku Zurek
 
Presentation on General Anesthetics pdf.
Presentation on General Anesthetics pdf.Presentation on General Anesthetics pdf.
Presentation on General Anesthetics pdf.Prerana Jadhav
 

Recently uploaded (20)

PNEUMOTHORAX AND ITS MANAGEMENTS.pdf
PNEUMOTHORAX   AND  ITS  MANAGEMENTS.pdfPNEUMOTHORAX   AND  ITS  MANAGEMENTS.pdf
PNEUMOTHORAX AND ITS MANAGEMENTS.pdf
 
Case Report Peripartum Cardiomyopathy.pptx
Case Report Peripartum Cardiomyopathy.pptxCase Report Peripartum Cardiomyopathy.pptx
Case Report Peripartum Cardiomyopathy.pptx
 
Measurement of Radiation and Dosimetric Procedure.pptx
Measurement of Radiation and Dosimetric Procedure.pptxMeasurement of Radiation and Dosimetric Procedure.pptx
Measurement of Radiation and Dosimetric Procedure.pptx
 
Report Back from SGO: What’s New in Uterine Cancer?.pptx
Report Back from SGO: What’s New in Uterine Cancer?.pptxReport Back from SGO: What’s New in Uterine Cancer?.pptx
Report Back from SGO: What’s New in Uterine Cancer?.pptx
 
Informed Consent Empowering Healthcare Decision-Making.pptx
Informed Consent Empowering Healthcare Decision-Making.pptxInformed Consent Empowering Healthcare Decision-Making.pptx
Informed Consent Empowering Healthcare Decision-Making.pptx
 
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment BookingCall Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
 
Apiculture Chapter 1. Introduction 2.ppt
Apiculture Chapter 1. Introduction 2.pptApiculture Chapter 1. Introduction 2.ppt
Apiculture Chapter 1. Introduction 2.ppt
 
Glomerular Filtration and determinants of glomerular filtration .pptx
Glomerular Filtration and  determinants of glomerular filtration .pptxGlomerular Filtration and  determinants of glomerular filtration .pptx
Glomerular Filtration and determinants of glomerular filtration .pptx
 
COVID-19 (NOVEL CORONA VIRUS DISEASE PANDEMIC ).pptx
COVID-19  (NOVEL CORONA  VIRUS DISEASE PANDEMIC ).pptxCOVID-19  (NOVEL CORONA  VIRUS DISEASE PANDEMIC ).pptx
COVID-19 (NOVEL CORONA VIRUS DISEASE PANDEMIC ).pptx
 
Primary headache and facial pain. (2024)
Primary headache and facial pain. (2024)Primary headache and facial pain. (2024)
Primary headache and facial pain. (2024)
 
Glomerular Filtration rate and its determinants.pptx
Glomerular Filtration rate and its determinants.pptxGlomerular Filtration rate and its determinants.pptx
Glomerular Filtration rate and its determinants.pptx
 
Call Girls Viman Nagar 7001305949 All Area Service COD available Any Time
Call Girls Viman Nagar 7001305949 All Area Service COD available Any TimeCall Girls Viman Nagar 7001305949 All Area Service COD available Any Time
Call Girls Viman Nagar 7001305949 All Area Service COD available Any Time
 
Statistical modeling in pharmaceutical research and development.
Statistical modeling in pharmaceutical research and development.Statistical modeling in pharmaceutical research and development.
Statistical modeling in pharmaceutical research and development.
 
call girls in dwarka DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in dwarka DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️call girls in dwarka DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in dwarka DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
 
call girls in green park DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in green park  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️call girls in green park  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in green park DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
 
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
 
Hematology and Immunology - Leukocytes Functions
Hematology and Immunology - Leukocytes FunctionsHematology and Immunology - Leukocytes Functions
Hematology and Immunology - Leukocytes Functions
 
call girls in paharganj DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in paharganj DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️call girls in paharganj DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in paharganj DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
 
See the 2,456 pharmacies on the National E-Pharmacy Platform
See the 2,456 pharmacies on the National E-Pharmacy PlatformSee the 2,456 pharmacies on the National E-Pharmacy Platform
See the 2,456 pharmacies on the National E-Pharmacy Platform
 
Presentation on General Anesthetics pdf.
Presentation on General Anesthetics pdf.Presentation on General Anesthetics pdf.
Presentation on General Anesthetics pdf.
 

Tb TUBERCULOSIS