SlideShare a Scribd company logo
PHThISIS
HISTORY
Mycobacterium tuberculosis
• A bacterium that resembles a fungus
• Multiply at varying rates
• Characterized as acid-fast aerobic
organisms
• Can be killed by heat, sunshine, drying
and UV exposure
MODE OF SPREAD
PATHOLOGY
• The bacillus of TB infect the lung,
forming a tubercle (lesion)
• May heal ,leaving a tissue / may continue
as a granuloma , then heal or be
reactivated / May eventually proceed to
necrosis and cavitation.
• The initial lesion may dessiminate
tubercle bacilli
 By extension to adjacent tissues
 Through bloodstream
 Through lymphatic system
 Through bronchi
CLINICAL MANIFESTATIONS
DIAGNOSTIC EVALUATION
• SPUTUM SMEAR- detection of acid-fast
bacilli in stained smears . First morning
sputum obatined on 3 consecutive days
• SPUTUM CULTURE- positive culture
confirmation.
• CHEST X-RAY- Extent of disease
• Tuberculin skin test-PPD or MANTOUX
test : inoculation of tubercule bacillus
extract into the intradermal layer of the
inner aspect of the forearm
• Used to detect active and inactive
infection
MANAGEMENT
• ANTI TUBERCULAR THERAPY: Daily
oral doses of isoniazid, rifampin, and
pyranizamide – 6 months.
• ANTI TUBERCULAR MEDICATIONS:
Streptomycin(15mg), ethnambutol(15-
25mg),rifampin(10mg) daily for 8 weeks
DOTS
• DOTS-Directly Observed Treatment ,
Short Course: WHO recommended TB
control strategy.
• Specially for patients with drug resistant
TB, HIV-infected patients, and those on
intermittent treatment regimens(2/3 times
weekly
PREVENTION
• Isolation
• Ventilation
• Personal protection
• Complete course of medications
• Vaccination
Pulmonary Tuberculosis - Phthisis[1].pptx
Pulmonary Tuberculosis - Phthisis[1].pptx
Pulmonary Tuberculosis - Phthisis[1].pptx
Pulmonary Tuberculosis - Phthisis[1].pptx

More Related Content

Similar to Pulmonary Tuberculosis - Phthisis[1].pptx

Cutaneous tuberculosis ( SKIN TB )
Cutaneous tuberculosis ( SKIN TB ) Cutaneous tuberculosis ( SKIN TB )
Cutaneous tuberculosis ( SKIN TB )
MOHAMMAD NOUR AL SAEED
 
Cutaneous tuberculosis
Cutaneous tuberculosisCutaneous tuberculosis
Cutaneous tuberculosis
Mohamed Fazly
 
ATYPICAL MYCOBACTERIAL INFECTIONS AND THEIR MANIFESTATIONS
ATYPICAL MYCOBACTERIAL INFECTIONS AND THEIR MANIFESTATIONSATYPICAL MYCOBACTERIAL INFECTIONS AND THEIR MANIFESTATIONS
ATYPICAL MYCOBACTERIAL INFECTIONS AND THEIR MANIFESTATIONS
DR. MOHNISH SEKAR
 
Tuberculosis
TuberculosisTuberculosis
Tuberculosis
micro1267
 
Mycobacterium
MycobacteriumMycobacterium
Mycobacterium
RabiaNaeem14
 
Mycobacterium
MycobacteriumMycobacterium
Mycobacterium
RabiaNaeem14
 
Tuberculoosis and antitubercular drugs
Tuberculoosis and antitubercular drugsTuberculoosis and antitubercular drugs
Tuberculoosis and antitubercular drugs
Narasimha Kumar G V
 
tkasjbjhJALKJDLKJKFWHSDGSHDHSJDDJJDHDHHD
tkasjbjhJALKJDLKJKFWHSDGSHDHSJDDJJDHDHHDtkasjbjhJALKJDLKJKFWHSDGSHDHSJDDJJDHDHHD
tkasjbjhJALKJDLKJKFWHSDGSHDHSJDDJJDHDHHD
HelloVintunnara
 
Mycobacterium Tuberculosis
Mycobacterium TuberculosisMycobacterium Tuberculosis
Mycobacterium Tuberculosis
Mary Mwinga
 
Tuberculosis... a brife description about it
Tuberculosis... a brife description about itTuberculosis... a brife description about it
Tuberculosis... a brife description about it
DrGireesha123
 
Tuberculosis
Tuberculosis Tuberculosis
Tuberculosis
Rohit kumar
 
MYCOBACTERIUM (3).pdf
MYCOBACTERIUM (3).pdfMYCOBACTERIUM (3).pdf
MYCOBACTERIUM (3).pdf
Mariam77865
 
Mycobacterium tuberculosis
Mycobacterium tuberculosisMycobacterium tuberculosis
Mycobacterium tuberculosis
subhalakshmi ramakrishnan
 
Mycobacterium tuberculosis
Mycobacterium tuberculosisMycobacterium tuberculosis
Mycobacterium tuberculosis
raghunathp
 
Mycobacterium
MycobacteriumMycobacterium
Mycobacterium
Mariam77865
 
Tuberculosis
TuberculosisTuberculosis
Tuberculosis
Afra Jamal
 
Tuberculosis
TuberculosisTuberculosis
Tuberculosis
varshitha Nakka
 
Cutaneous manifestations of tb
Cutaneous manifestations of tbCutaneous manifestations of tb
Cutaneous manifestations of tb
DR RML DELHI
 
Cutaneous manifestations of tb
Cutaneous manifestations of tbCutaneous manifestations of tb
Cutaneous manifestations of tb
DR RML DELHI
 
Mycobacterium tuberculosis
Mycobacterium  tuberculosisMycobacterium  tuberculosis
Mycobacterium tuberculosis
Dr. Samira Fattah
 

Similar to Pulmonary Tuberculosis - Phthisis[1].pptx (20)

Cutaneous tuberculosis ( SKIN TB )
Cutaneous tuberculosis ( SKIN TB ) Cutaneous tuberculosis ( SKIN TB )
Cutaneous tuberculosis ( SKIN TB )
 
Cutaneous tuberculosis
Cutaneous tuberculosisCutaneous tuberculosis
Cutaneous tuberculosis
 
ATYPICAL MYCOBACTERIAL INFECTIONS AND THEIR MANIFESTATIONS
ATYPICAL MYCOBACTERIAL INFECTIONS AND THEIR MANIFESTATIONSATYPICAL MYCOBACTERIAL INFECTIONS AND THEIR MANIFESTATIONS
ATYPICAL MYCOBACTERIAL INFECTIONS AND THEIR MANIFESTATIONS
 
Tuberculosis
TuberculosisTuberculosis
Tuberculosis
 
Mycobacterium
MycobacteriumMycobacterium
Mycobacterium
 
Mycobacterium
MycobacteriumMycobacterium
Mycobacterium
 
Tuberculoosis and antitubercular drugs
Tuberculoosis and antitubercular drugsTuberculoosis and antitubercular drugs
Tuberculoosis and antitubercular drugs
 
tkasjbjhJALKJDLKJKFWHSDGSHDHSJDDJJDHDHHD
tkasjbjhJALKJDLKJKFWHSDGSHDHSJDDJJDHDHHDtkasjbjhJALKJDLKJKFWHSDGSHDHSJDDJJDHDHHD
tkasjbjhJALKJDLKJKFWHSDGSHDHSJDDJJDHDHHD
 
Mycobacterium Tuberculosis
Mycobacterium TuberculosisMycobacterium Tuberculosis
Mycobacterium Tuberculosis
 
Tuberculosis... a brife description about it
Tuberculosis... a brife description about itTuberculosis... a brife description about it
Tuberculosis... a brife description about it
 
Tuberculosis
Tuberculosis Tuberculosis
Tuberculosis
 
MYCOBACTERIUM (3).pdf
MYCOBACTERIUM (3).pdfMYCOBACTERIUM (3).pdf
MYCOBACTERIUM (3).pdf
 
Mycobacterium tuberculosis
Mycobacterium tuberculosisMycobacterium tuberculosis
Mycobacterium tuberculosis
 
Mycobacterium tuberculosis
Mycobacterium tuberculosisMycobacterium tuberculosis
Mycobacterium tuberculosis
 
Mycobacterium
MycobacteriumMycobacterium
Mycobacterium
 
Tuberculosis
TuberculosisTuberculosis
Tuberculosis
 
Tuberculosis
TuberculosisTuberculosis
Tuberculosis
 
Cutaneous manifestations of tb
Cutaneous manifestations of tbCutaneous manifestations of tb
Cutaneous manifestations of tb
 
Cutaneous manifestations of tb
Cutaneous manifestations of tbCutaneous manifestations of tb
Cutaneous manifestations of tb
 
Mycobacterium tuberculosis
Mycobacterium  tuberculosisMycobacterium  tuberculosis
Mycobacterium tuberculosis
 

More from PREETHYDAVID

Virus Indexing methods
Virus Indexing methodsVirus Indexing methods
Virus Indexing methods
PREETHYDAVID
 
Stm and afm ppt
Stm and afm pptStm and afm ppt
Stm and afm ppt
PREETHYDAVID
 
Dna replication in virus ppt
Dna replication in virus pptDna replication in virus ppt
Dna replication in virus ppt
PREETHYDAVID
 
Pericardial diseases part ii
Pericardial diseases part iiPericardial diseases part ii
Pericardial diseases part ii
PREETHYDAVID
 
Pericardial diseases part i
Pericardial diseases part   iPericardial diseases part   i
Pericardial diseases part i
PREETHYDAVID
 
Gantt chart
Gantt chartGantt chart
Gantt chart
PREETHYDAVID
 
Bench marking
Bench markingBench marking
Bench marking
PREETHYDAVID
 
Pert n gantt
Pert n gantt Pert n gantt
Pert n gantt
PREETHYDAVID
 
Myocardial infarction
Myocardial infarction  Myocardial infarction
Myocardial infarction
PREETHYDAVID
 
Stages of seed development
Stages of seed developmentStages of seed development
Stages of seed development
PREETHYDAVID
 
Map based cloning
Map based cloning Map based cloning
Map based cloning
PREETHYDAVID
 
Marker assisted foreground & background selection in soybean
Marker assisted foreground & background selection in soybeanMarker assisted foreground & background selection in soybean
Marker assisted foreground & background selection in soybean
PREETHYDAVID
 

More from PREETHYDAVID (12)

Virus Indexing methods
Virus Indexing methodsVirus Indexing methods
Virus Indexing methods
 
Stm and afm ppt
Stm and afm pptStm and afm ppt
Stm and afm ppt
 
Dna replication in virus ppt
Dna replication in virus pptDna replication in virus ppt
Dna replication in virus ppt
 
Pericardial diseases part ii
Pericardial diseases part iiPericardial diseases part ii
Pericardial diseases part ii
 
Pericardial diseases part i
Pericardial diseases part   iPericardial diseases part   i
Pericardial diseases part i
 
Gantt chart
Gantt chartGantt chart
Gantt chart
 
Bench marking
Bench markingBench marking
Bench marking
 
Pert n gantt
Pert n gantt Pert n gantt
Pert n gantt
 
Myocardial infarction
Myocardial infarction  Myocardial infarction
Myocardial infarction
 
Stages of seed development
Stages of seed developmentStages of seed development
Stages of seed development
 
Map based cloning
Map based cloning Map based cloning
Map based cloning
 
Marker assisted foreground & background selection in soybean
Marker assisted foreground & background selection in soybeanMarker assisted foreground & background selection in soybean
Marker assisted foreground & background selection in soybean
 

Recently uploaded

share - Lions, tigers, AI and health misinformation, oh my!.pptx
share - Lions, tigers, AI and health misinformation, oh my!.pptxshare - Lions, tigers, AI and health misinformation, oh my!.pptx
share - Lions, tigers, AI and health misinformation, oh my!.pptx
Tina Purnat
 
Diabetic nephropathy diagnosis treatment
Diabetic nephropathy diagnosis treatmentDiabetic nephropathy diagnosis treatment
Diabetic nephropathy diagnosis treatment
arahmanzai5
 
Top-Vitamin-Supplement-Brands-in-India List
Top-Vitamin-Supplement-Brands-in-India ListTop-Vitamin-Supplement-Brands-in-India List
Top-Vitamin-Supplement-Brands-in-India List
SwisschemDerma
 
Hemodialysis: Chapter 4, Dialysate Circuit - Dr.Gawad
Hemodialysis: Chapter 4, Dialysate Circuit - Dr.GawadHemodialysis: Chapter 4, Dialysate Circuit - Dr.Gawad
Hemodialysis: Chapter 4, Dialysate Circuit - Dr.Gawad
NephroTube - Dr.Gawad
 
Cell Therapy Expansion and Challenges in Autoimmune Disease
Cell Therapy Expansion and Challenges in Autoimmune DiseaseCell Therapy Expansion and Challenges in Autoimmune Disease
Cell Therapy Expansion and Challenges in Autoimmune Disease
Health Advances
 
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...
Oleg Kshivets
 
THERAPEUTIC ANTISENSE MOLECULES .pptx
THERAPEUTIC ANTISENSE MOLECULES    .pptxTHERAPEUTIC ANTISENSE MOLECULES    .pptx
THERAPEUTIC ANTISENSE MOLECULES .pptx
70KRISHPATEL
 
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotes
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPromoting Wellbeing - Applied Social Psychology - Psychology SuperNotes
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotes
PsychoTech Services
 
Part II - Body Grief: Losing parts of ourselves and our identity before, duri...
Part II - Body Grief: Losing parts of ourselves and our identity before, duri...Part II - Body Grief: Losing parts of ourselves and our identity before, duri...
Part II - Body Grief: Losing parts of ourselves and our identity before, duri...
bkling
 
Netter's Atlas of Human Anatomy 7.ed.pdf
Netter's Atlas of Human Anatomy 7.ed.pdfNetter's Atlas of Human Anatomy 7.ed.pdf
Netter's Atlas of Human Anatomy 7.ed.pdf
BrissaOrtiz3
 
Ketone bodies and metabolism-biochemistry
Ketone bodies and metabolism-biochemistryKetone bodies and metabolism-biochemistry
Ketone bodies and metabolism-biochemistry
Dhayanithi C
 
K CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấu
K CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấuK CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấu
K CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấu
HongBiThi1
 
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdfCHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
rishi2789
 
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kol...
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kol...TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kol...
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kol...
rightmanforbloodline
 
Journal Article Review on Rasamanikya
Journal Article Review on RasamanikyaJournal Article Review on Rasamanikya
Journal Article Review on Rasamanikya
Dr. Jyothirmai Paindla
 
Osteoporosis - Definition , Evaluation and Management .pdf
Osteoporosis - Definition , Evaluation and Management .pdfOsteoporosis - Definition , Evaluation and Management .pdf
Osteoporosis - Definition , Evaluation and Management .pdf
Jim Jacob Roy
 
Efficacy of Avartana Sneha in Ayurveda
Efficacy of Avartana Sneha in AyurvedaEfficacy of Avartana Sneha in Ayurveda
Efficacy of Avartana Sneha in Ayurveda
Dr. Jyothirmai Paindla
 
Complementary feeding in infant IAP PROTOCOLS
Complementary feeding in infant IAP PROTOCOLSComplementary feeding in infant IAP PROTOCOLS
Complementary feeding in infant IAP PROTOCOLS
chiranthgowda16
 
A Classical Text Review on Basavarajeeyam
A Classical Text Review on BasavarajeeyamA Classical Text Review on Basavarajeeyam
A Classical Text Review on Basavarajeeyam
Dr. Jyothirmai Paindla
 
CHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdf
CHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdfCHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdf
CHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdf
rishi2789
 

Recently uploaded (20)

share - Lions, tigers, AI and health misinformation, oh my!.pptx
share - Lions, tigers, AI and health misinformation, oh my!.pptxshare - Lions, tigers, AI and health misinformation, oh my!.pptx
share - Lions, tigers, AI and health misinformation, oh my!.pptx
 
Diabetic nephropathy diagnosis treatment
Diabetic nephropathy diagnosis treatmentDiabetic nephropathy diagnosis treatment
Diabetic nephropathy diagnosis treatment
 
Top-Vitamin-Supplement-Brands-in-India List
Top-Vitamin-Supplement-Brands-in-India ListTop-Vitamin-Supplement-Brands-in-India List
Top-Vitamin-Supplement-Brands-in-India List
 
Hemodialysis: Chapter 4, Dialysate Circuit - Dr.Gawad
Hemodialysis: Chapter 4, Dialysate Circuit - Dr.GawadHemodialysis: Chapter 4, Dialysate Circuit - Dr.Gawad
Hemodialysis: Chapter 4, Dialysate Circuit - Dr.Gawad
 
Cell Therapy Expansion and Challenges in Autoimmune Disease
Cell Therapy Expansion and Challenges in Autoimmune DiseaseCell Therapy Expansion and Challenges in Autoimmune Disease
Cell Therapy Expansion and Challenges in Autoimmune Disease
 
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...
 
THERAPEUTIC ANTISENSE MOLECULES .pptx
THERAPEUTIC ANTISENSE MOLECULES    .pptxTHERAPEUTIC ANTISENSE MOLECULES    .pptx
THERAPEUTIC ANTISENSE MOLECULES .pptx
 
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotes
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPromoting Wellbeing - Applied Social Psychology - Psychology SuperNotes
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotes
 
Part II - Body Grief: Losing parts of ourselves and our identity before, duri...
Part II - Body Grief: Losing parts of ourselves and our identity before, duri...Part II - Body Grief: Losing parts of ourselves and our identity before, duri...
Part II - Body Grief: Losing parts of ourselves and our identity before, duri...
 
Netter's Atlas of Human Anatomy 7.ed.pdf
Netter's Atlas of Human Anatomy 7.ed.pdfNetter's Atlas of Human Anatomy 7.ed.pdf
Netter's Atlas of Human Anatomy 7.ed.pdf
 
Ketone bodies and metabolism-biochemistry
Ketone bodies and metabolism-biochemistryKetone bodies and metabolism-biochemistry
Ketone bodies and metabolism-biochemistry
 
K CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấu
K CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấuK CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấu
K CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấu
 
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdfCHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
 
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kol...
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kol...TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kol...
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kol...
 
Journal Article Review on Rasamanikya
Journal Article Review on RasamanikyaJournal Article Review on Rasamanikya
Journal Article Review on Rasamanikya
 
Osteoporosis - Definition , Evaluation and Management .pdf
Osteoporosis - Definition , Evaluation and Management .pdfOsteoporosis - Definition , Evaluation and Management .pdf
Osteoporosis - Definition , Evaluation and Management .pdf
 
Efficacy of Avartana Sneha in Ayurveda
Efficacy of Avartana Sneha in AyurvedaEfficacy of Avartana Sneha in Ayurveda
Efficacy of Avartana Sneha in Ayurveda
 
Complementary feeding in infant IAP PROTOCOLS
Complementary feeding in infant IAP PROTOCOLSComplementary feeding in infant IAP PROTOCOLS
Complementary feeding in infant IAP PROTOCOLS
 
A Classical Text Review on Basavarajeeyam
A Classical Text Review on BasavarajeeyamA Classical Text Review on Basavarajeeyam
A Classical Text Review on Basavarajeeyam
 
CHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdf
CHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdfCHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdf
CHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdf
 

Pulmonary Tuberculosis - Phthisis[1].pptx

  • 2.
  • 3.
  • 6. • A bacterium that resembles a fungus • Multiply at varying rates • Characterized as acid-fast aerobic organisms • Can be killed by heat, sunshine, drying and UV exposure
  • 7.
  • 9. PATHOLOGY • The bacillus of TB infect the lung, forming a tubercle (lesion) • May heal ,leaving a tissue / may continue as a granuloma , then heal or be reactivated / May eventually proceed to necrosis and cavitation.
  • 10. • The initial lesion may dessiminate tubercle bacilli  By extension to adjacent tissues  Through bloodstream  Through lymphatic system  Through bronchi
  • 11.
  • 12.
  • 13.
  • 14.
  • 15.
  • 17.
  • 18. DIAGNOSTIC EVALUATION • SPUTUM SMEAR- detection of acid-fast bacilli in stained smears . First morning sputum obatined on 3 consecutive days • SPUTUM CULTURE- positive culture confirmation. • CHEST X-RAY- Extent of disease
  • 19. • Tuberculin skin test-PPD or MANTOUX test : inoculation of tubercule bacillus extract into the intradermal layer of the inner aspect of the forearm • Used to detect active and inactive infection
  • 20.
  • 21. MANAGEMENT • ANTI TUBERCULAR THERAPY: Daily oral doses of isoniazid, rifampin, and pyranizamide – 6 months. • ANTI TUBERCULAR MEDICATIONS: Streptomycin(15mg), ethnambutol(15- 25mg),rifampin(10mg) daily for 8 weeks
  • 22. DOTS • DOTS-Directly Observed Treatment , Short Course: WHO recommended TB control strategy. • Specially for patients with drug resistant TB, HIV-infected patients, and those on intermittent treatment regimens(2/3 times weekly
  • 23.
  • 24.
  • 25.
  • 26.
  • 27. PREVENTION • Isolation • Ventilation • Personal protection • Complete course of medications • Vaccination