Disease Process

PARASITES a) Ascariasis (Round worm)

Etiologic Agent

Mode of transmission
fecal to oral

Signs and Symptoms

Diagnostic Test

IP/POC

Drug of Choice

Comments

Ascaris Lumbricoides

Parasites in stool and vomitus, Intestinal Obstruction, Abdominal Pain

Stool Analysis

Ip= 60-75d Poc= as long as egg present on feces

Benzimidazoles (inhibits the uptake of glucose) Mebendazole Albendazole Piperacine Citrate & Pyrantel Pamoate (paralyze the worm)

b) Enterobiasis (pinworm, sitworm, threadworm, oxyuriasis) c) Hookworm

Enterobius vermicularis

fecal to oral

Pruritus Ani irritability restlessness and agitation CXS: salphingitis, vaginitis Ground Itch anemia, cyanocobalamin deficiency, malnutrition GI bleeding abdominal pain poor growth Cystecercosis-infective stage Nausea, diarrhea, flatulence, hunger sensation, wt. loss, unexplained anemia, increase appetite diarrhea, vomiting, anorexia, failure to thrive, abdominal cramps, intermittent LBM(foul,pale,greasy)

Scotch Tape Test (Grahams test) fecalysis

same as above

C-lothing-wash w/ soap and water H-ave pets checked regularly A-dditional sanitation measures S-hort and clean fingernails E-valuate the source of infection migrates to vagina, urethra, anus at night Treat all household members wear shoes and slippers outside feeds on villi

Necatur americanus, Ancylostoma dounale

direct contact with infected soil containing larvae Fecal-oral Dried foods fecal to oral Improperly cooked foods fecal to oral

fecalysis

same as above

d) Whipworm e) Taeniasis (tapeworm)

Trichuris trichuria T. saginata- beef T. solium- pork T. latum- fish

fecalysis Fecalysis Inmmunologic testdetects cystecerci IP= 5-12 wks POC=

Mebendazole Niclosamide

Proper disposal of feces Proper food selection and preparation

f) Giardiasis

Giardia lamblia

unfiltered water improperly cooked food

fecalysis

Furozolidone Quinacrine metronidazole

infection may resolve spontaneously in 4-6 wks w/o ttt wear gloves when handling diapers in stools

g) Amoebiasis

Entamoeba histolytica

fecal to oral

Diarrhea abdl cramps tenesmus blood tinged stool complications: (liver, lung, brain abscess)

stool exam serologic exam

Metronidazole Fluid replacement

no antidiarrheals hygiene cook foods properly

VECTOR BORNE a) Malaria (ague)

P. Knowlesi, Falciparum, Malariae,Ovale, Vivax

Female Anopheles Mosquito(9pm3am) Blood Transfusion Needle Stick Injury

Black Water Fever- intravascular hemolysis and hemoglobinuria (mahogany colored) Cerebral Malaria hepatosplenomegaly Stiff neck Fever

Blood smear History of travel

IP= 7-12 days

Quinine ArthemetherLumefantrine (IMCI 1st line) Chloroquine(prophylaxis, 500mg/wk same time and day) Sulfadoxine Primaquine Pyrimethamine Supportive Therapy Rehydration Manage shock Blood transfusion- platelet concentrate, FFP Bland food Mycophenolic Acid and Ribavirin- inhibits dengue replication

No aspirin indls with sickle cell trait have natural resistance to malaria assess travel history S/e of drugs: tinnitus, vertigo, deafness Plant NEEM tree C-aseDiagnosis H-ealth education R-apid response I-ntegrated vector control S-urveillance T-rainings *No aspirin

b) Dengue Hemorrhagic Fever

Dengue virus 1,2,3,4 Chikungunya virus *Resides in Clean Water

Day Biting Female Aedes agypti (6-8am, 4-6pm)

c) Paragonomiasis

Paragonimus westermani

Ingestion of improperly cooked or contaminated food Freshwater Crabs (Antemelata asperata) and Snails

Stages I- Fever and abdominal pain, (+) tourniquet test( aka Rumpel leads test, Capillary Fragility test) II- Stage 1 + spontaneous bleeding III- stages 1&2 + circulatory failure, weak thready pulse, hypotension, restlessness IV-Stages 1-3 + profound shock, undetectable pulse and BP, thrombocytopenia PTB like Symptoms- not responding to anti TB meds cough in long duration hemoptysis recurrent blood streaked sputum chest or back pain

Tourniquet Testscreening Platelet countconfirmatory

Ip- 6d-1 week

Praziquantel (Biltrizide) Bithionol (2nd line)

avoid eating raw or undercooked freshwater crabs and crayfish

d) Schistosomiasis (snail fever, bilhariasis, swimmers itch)

e) Leptospirosis (Weils disease, Mud fever, Swine herds disease, Canicola fever, Trench Fever, Spirochetal jaundice, Japanese 7 days fever) f) Filariasis (elephantiasis)

Schistosoma: mansoni-intestine hematobiumblood japonicumintestines L. interrogans L. canicola

ingestion of Snail vector (Oncomelania quadrasi) or larvae penetrates the skin Skin contact of open wound w/ water, moist soil or vegetation contaminated w/ urine of infected host

diarrhea, bloody stools hematuria hepatosplenomegaly abdominal distension S. Japonicum- causes Katayama disease Leptospiremic Stage: spiking fever, h/a, cough and chest pain Immune Phase: icteric sclera/ non-icteric hematuria

Kato Katz techinique

Praziquantel for all species Oxapinique- S. Mansoni Metrifonate- S. hematobium Penicillin Beta-Lactam Antibiotics Tetracyclines Doxycycline (chemoprophylaxis)

add iodine and chlorine in water to kill cercariae(fluke gets out of the snail and becomes infective) avoid wading in contaminated water and wear boots rat eradication

Cultures: blood, CSF, Urine Agglutination tests

Wuchereria bancrofti Brugia malayi and timori

Night biting mosquito vector: Aedes poecillus (10pm-12am) Aedes flavirostris (10pm-2am)

Asymptomatic microfilariae in the blood Acute lympadenitis, lymphangitis, orchitis Chronic hydrocele, elephantiasis, lymphedema

Nocturnal Blood Exam (NBE)- done after 8pm Inmmunochromatographic Test (ICT)- rapid assessment method of antigen, done at AM Stool Exam Dark field microscopy- (+) shooting stars IP= few hours to 3 days POC= 7-14 days IP= 3-4 days

Diethylcarbamazine citrate (Hetrezan)

environmental sanitation spraying of insecticide mosquito net screen house windows

Diarrheal Diseases a) Cholera (El tor)

Vibrio cholera Vibrio coma

fecal to oral

Watch out! 3 Ds D-iarrhea D-ehydration D-eath Rice Watery Stool Washerwomans Hand Bloody Mucoid stools Tenesmus-painful straining frequent bloody and watery stools abdominal cramps

Tetracyline (IMCI) Supportive(IVF and ORESOL) buko juice- for potassium loss

safe, clean, food, water hygiene continue breastfeeding

b)Bacillary Dysentery (travellers disease, shigellosis, bloody flux)

Shigella: sonnei boydii dysenteriae flexnerii

5Fs F-ood F-luids F-lies F-eces F-omites

Ciprofloxacin(IMCI) Fluoroquinolones Cotrimoxazole

Safe food handling sanitary disposal of excreta fly control water sanitation

c) Typhoid fever (enteric fever, typhus abdominalis)

Salmonella typhosa that attacks GALT(peyers patches)

ingestion of contaminated food or water

Prodromal fever, abdominal pain, diarrhea Fastigial Stage L-adder like fever R-ose spots- rose colored macule that disappears after applying pressure on abdomen and chest S-plenomegaly Typhoid Psychosis Stage -organism goes to the brain s/sx: CA-rphalogia- involuntary picking of lines SU-bsltus tendinum- involuntary twitching of the tendons of the wrist CO-ma vigil- blank-look stare

Widal Test- done on 8th day or 2nd stage FOBT/ Guaiac Typhi dot Rectal Swab

Chloramphenicol (s/e: thrombocytopenia and anemia) ampicillin sulfamehoxazole trimethoprim

immunization of CDT: (cholera, dysentery, typhoid) proper disposal of feces handwashing safe food handling

CHILDHOOD DSES a) Varicella (chicken pox)

Varicella zoster

respiratory tract secretions skin lesions

Maculo>Papular>Vesicular Lesions (Centrifugal spread) highly pruritic rash

Tzanck Smear

Ip= 14-17 d Poc= until the eruption of the last vesicle

CX: Secondary Infection: furuncles (abscess formation) and erysipelas(vesicular edematous) Pneumonia Sepsis Reyes syndrome pustular (pus-filled) pimples resembling boils

supportive antivirals- for serious cases antihistamines- for itching Isoprinosine-coats virus and boosts immune system calamine lotions/baking soda- for itching

No aspirin trim nails wear mittens

b) Small pox

variola virus

droplet and direct contact

ip=10-12d poc=3rd to 8th day after onset of fever

c) Measles (7 day measles)

Filtrable virus Rubeola morbilii paramyxovirus

Airborne

Koplik Spots- small irregular red spots w/ tiny bluish center at the buccal mucosa Stimsons sign- inflammation along the margin of the eyelids 3 Cs( cough, coryza, conjunctivitis) maculopapular rash(cepalocaudal) CXS: keratomalacia, mouth ulcers, pus draining in the eye, photophobia *NO lymphnode enlargement Forescheimers spots- reddish spots on soft palate (+) Lymph node involvement (post-auricular, post-cervical, sub-occipital) Starts from the abdomen (centrifugal) Complications: Congenital Rubella Thrombocytopenia Purpura Cardiac Defects (PDA,ASD,VSD) Eye defects (cataract/glaucoma) Hearing loss Microcephaly, mental retardation Wharton and Stensens sign Cx: NUchal rigidity Nephritis Unilateral deafness Orchitis/oopheritis (adults) Convulsion & delirium Meningitis (children)

Complement fixationconfirmatory

ip= 1014days poc=4d b4 and 5d after the appearanc e of rashes

d) German measles (3 day measles)

Rubella virus Togavirus

Droplet/Placental

Rubella Titer Test Otoacoustic Emission Testing- 1st day upon birth of newborn

IP= 14-21 days POC= 3-5 days

supportive eye care -dim lights(due to photosensitivity) -cleanse eyelids w/ warm saline to remove crust -prevent rubbing -examine eyes for corneal laceration Coryza -use cool mist vaporizer -protect nares w/ petroleum jelly Skin care -TSB Supportive Increase fluid intake

measles vaccine- live attenuated grown in chick embryo (causes hypersensitivity rxn) MMR- after 1st b-day 2nd dose- 4-6 y/o *no pregnancy after 4 wks

*Has teratogenic effect on the fetus if acquired by a pregnant mother *delay pregnancy for 3 months after immunization and positive for rubella titer test

e) Mumps (epidemic parotitis)

Pramyxovirus (filterable)

Droplet/direct contact

Serum amylase determination

IP= 18d Poc= 6 d before and 9 d after swelling

Antiviral acyclovir Symptomatic treatment Oral care Isolation Diet: SOFT

MMR Bedrest and Isolation The scrotum should be supported by a properly fitted pillow, or a sling between the thighs to relieve the pull of gravity

Sour food or fruits juices Ice collar f) Poliomyelitis (infantile paralysis, Heine Medin paralysis, acute flaccid paralysis) Legio debilitans Polio virus resides at ant.horn of spine Types I- Brunhilde II-Lansing III- Leon Fecal to oral route Types: 1. Subclinical/Asymptomatic/sil e-nt 2. Abortive- 95% (-) CNS Sore throat, h/a, LGF, vomiting, Low lumbar pain 3. Non- paralytic Abortive + muscle spasm Change in reflexes 4. ParalyticHoynes Sign- head fall, shoulder is elevated, and legs are painful when in 90 degrees Kernings and Brudzinkis sign Invasive or catarrhal stage Spasmodic StageWhooping cough (inspiratory whoop> spasmodic cough with explosive expiration> vomiting) Convalescent stage Pandys testextraction of CSF and if w/ precipitate (+) for polio Ip=7-14 d Supportive Care Physical therapy, braces or corrective shoes, orthopedic surgery Moist heat may reduce muscle pain and spasm Immunization SALK- solution of killed vaccine SABIN- attenuated viruses

g) Pertussis (whooping cough syndrome, 100/day cough, Tuspirina)

Hemophilus Perstussis (aerobic) Bordetella Pertussis (anaerobic)

Nasopharyngeal secretions

Nasal Swabs Bordet Gengou Agar Plate

IP= 7-21 days POC= 3 upt0 weeks after the paroxysm

C-larithromycin E-rythromycin A-zithromycin S-inecod

Cough at the edge of the chair/use abdominal binder/ abdominal splinting- to prevent rectal herniation or prolapsed Dont smoke Avoid fresh flowers Dont remove pseudomembrane because can cause bleeding and spread

h) Diphtheria

Corynebacterium diphtheria Klebs-Loeffler Bacillus

Discharge from respiratory passages a saliva

Nasal Diphtheria: Irritating, bloody discharges Laryngeal Diphtheria: (most dangerous) Croupy Cough Laryngeal obstruction Pharyngeal Diphtheria: *Bull Neck Appearance/pseudomembrane on throat/saliva

Nose and Throat culture Schicks test- test for susceptibility and resistance to the bacteria Moloneys testhypersensitivity to diphtheria toxin

IP= 2-5 days POC= 2-4 weeks

Penicillin Erythromycin ( c/I for children bec. can cause teeth obstruction) Ampicillin

i) Tetanus (Lock Jaw)

Clostridium tetani Toxins: Tenanospasminaffects nerves specifically myoneural junction of muscles Tetanolysin- has a deadly effect; lysis or destruction of RBC and WBC

Break in the skin/ umbilical stump

Lock Jaw Risus Sardonicus- facial nerve is affected Trismus- painful spasms of masticatory muscles Opisthotonus- severe arching of the back

IP= 3-14 days

Penicillin Supportive Diazepam, Phenobarbitalfor muscular spasms Mephenesin- muscle relaxant

ATS (IM) Tetanus Antitoxin (IV) TIG ( Tetanus Immune Globulin) HHG- Human Hyperimmune Globulin Vaccination- DPT TT 1-2: no child protection TT- 3-5: child protection of 1 year

Venereal Diseases a) Gonorrhea (gonococcal, Drip, Clap, flow of seed)

Neisseria gonorrhoeae

contact with penis, vagina, mouth or anus From mother to baby during delivery Direct contact w/ infectious sore Discharges/blood containing the microorganism

possibly asymptomatic Profuse yellow green vaginal discharge

Thayer-Martin Medium/cultureconfirmatory gram staining

IP= 2-10 days

Ceftriaxone Doxycycline oral amoxicillin

*causes ophthalmic neonatorum

b) Syphilis ( Bad blood, The Pox)

Treponema pallidum

Stage I Painless ulcer (chancre) on vulva or vagina Stage II Condyloma accuminata/latamacular like rashes Stage III Gumma- tumor like masses Non-infectious stage Thin, irritating, frothy gray-green discharge strong putrid odor itching

Dark Field Illumination test Fluorescent Treponemal antibody Absorb Test Floculation test Kalm test VDRL Test

IP= 10 days to 3 months

Benzanthine penicillin via Intramuscular route Oral penicillin

*congenital syphilis causes hydrops fetalis

c) Trichomoniasis

Trichomonas vaginalis

d) Herpes Virus type II

Herpes Simplex Virus Type II

Direct skin /sexual contact

Painful pinpoint vesicles on a erythematous base with a

Direct Fluorescent Antibody Test

IP= 212days

Metronidazole (flagyl) orally Douching with weak vinegar solution to reduce pruritus bathing with dilute sodium bicarbonate

(genitalis)waste down

watery vaginal discharge voiding may be irritating and painful

Tzanck smear

solution, applying lubricating jelly to lesions or an oral analgesic such as aspirin may be necessary for pain relief; topical Acyclovir (Zovirax) helps heal lesions Metronidazole (flagyl) Clindamycin

e) Gardnerella

Gardnerella vaginalis Chlamydia trachomatis

f) Chlamydia

Edema and reddening of vulva, milky gray discharge, fishlike odor Watery, gray-white, vaginal discharge, fishlike odor

Culture

g) Candidiasis (moniliasis, thrush) i) HPV (Vietnam rose) OTHERS a) Rabies (Lyssa, Hydrophobia)

Candida albicans

Vulvar reddening and pruritus Thick, White, cheese like vaginal discharge Genital Warts Cauliflower lesions

culture

Human Papilloma Virus

Hematologic exam

Doxycycline tetracycline Erythromycin- during pregnancy Nystatin Micronazole (Monistat) suppositories Fluconazole (Difflucan) Cryoprobe Podifilox

Immunization: Giardasil Cervarix Vaccines- 5 doses 1. active verorab or Rabipur (waist down bite) 2. Passive anti-rabies serum or Equine Rabies Immunoglobulin (waistup infection) Be a responsible pet owner *vaccines are difficult to develop due to rapid mutation

Rhabdovirus types: street virus Fixed virus

saliva bite, non-bite, scratching, organ transplant(corneal)

Man Stiff neck, Headache, Hydrophobia(pharyngospasm), Aerophobia-laryngospasm, Respiratory Difficulty, Excessive Salivation Dog dumb/paralytic (dog is lethargic and w/ drooling episodes Furious- dog becomes aggressive

Flourescent Rabies Antibody (FRA) Technique - FRA is allowed to react with its specific antigens in culture or smear and the result is in precipitate form positive Brain Biopsy- detect presence of Negri Bodies (from the brain of the dog) 1st= Enzyme Link Immunosorbent

No specific For dog bite -wash with soap under running water for 15 minutes -seek consultation Give ATS and TT Amoxicillin

b) Acquired Immune Deficiency

Human immunodeficiency virus

Transmission sources: Blood and blood

Window period before seroconversion- 3-6 months Category A

1. Nucleoside Reverse Transcriptase Inhibitors

Syndrome (formerly GRIDSGay Related Immune Deficiency Syndrome)

products Semen/vaginal secretions Breast milk MOT: Unprotected penetrative sex w/ infected partner Blood transfusion Vertical(utero, delivery, breastfeeding)

Asymptomatic >500 CD4/uL Lymphadenopathy Category B Symptomatic 200-499 CD4/uL CD4 gradually fail Candida albicans, shingles, hairy leukoplakia, diarrhea, fever, PID, cervical dysplasia Category C (10yrs) Clinical AIDS <200 CD4/uL CMV, toxoplasmosis, PTB, mycobacterium avium complex, Non-hodgkins lymphoma, KAPOSIs sarcoma and PNEUMOCYSTIS CARINII

Assay (adult) and P24/Polymerase Chain reaction (child) *done TWICE for screening 2nd= Western Blotconfirmatory

*Zidovudine(retrovir)a/e: agranulocytopenia and anemia DIdanosine- a/e: pancreatitis, n/c: monitor serum amylase and lipase Zalcitabine- effective if theres increase in CD4 count Stavudine(d4t, Zent)- A/E: peripheral neuropathy, N/C: monitor gait and paresthesia Pentamidine-for P. carinii infection, A/E: leukopenia, anemia and thrombocytopenia 2. Non-Nucleoside Reverse Transcriptase Inhibitors Nevirapine (Viramune)S/E: headache, elevated liver enzymes, nausea A/E: heapatotoxic, rash (may progress to toxic epidermal necrolysis) 3. Protease Inhibitors Saquinavir( Fortovace)increase CHO and fat in the diet Acyclovir- N/C: Slow IV infusion for 1 hour, S/E:

Isolation: Reverse/ protective and blood and Body fluids precaution Medical asepsis

phlebitis and inflammation at site, Nephrotoxic Ganciclovir- S/E: neutropenia and thrombocytopenia Foscavir- nephrotoxic Paucibacillary Tuberculoid and indeterminate non-infectious DOC: Rifampicin & Dapsone (69 months ttt) Multibacillary Lepromatous and borderline Infectious type DOC: Rifampicin, Dapsone, Clofazimine (24-30 months) *Single Lesion and (-) Slit Skin Smear DOC: Rifampicin, Ofloxacin, Minocycline Rifampicin -Taken on empty stomach -causes orange discoloration of secretion and urine -store in an dark/amber colored container Isoniazid

a) Leprosy (Hansens disease, Lepra, Hansenosis, Leontiasis)

Mycobacterium leprae Hansens bacillus

Oronasal discharges prolonged skin to skin contact

Early P-ainful thickened nerves L-oss of sweat O-bstruction/epistaxis U-lcers that dont heal C-hange in color of skin Late ( U SMELL LIKE LION) U-lcers are chronic S-inking of nose bridge M-adarosis E-nlargement of breast L-agopthalmos LIONING FACE/Leonine face

Slit Skin Smear Lepromin test-cross infection test

IP= it may be shour as 1 year or as long as 5 years or more poc= as long as there are open lesions

*patient is noninfectious a week after starting treatment Clofazimine(Lamprene)MDT drug that causes darkening of the skin *dapsone- s/e: increase in the number of lesions *if dapsone is not effective give= ETHIONAMIDE

b) Pulmonary Tuberculosis (Kochs pulmonale, Phthisis)

PTBMycobacterium Tuberculosis, Bovis, Africanum Bone TB- Pots Diseases

Airborne Droplet Method

W-eight loss H-emoptysis E-asy fatigability N-ight sweats P-roductive cough O-rthopnea P-leuritic chest pain

Direct Sputum Smear IP= 4-8 wks Microscopy/ Sputum Smear and Culture Result: 0- negative bacilli +1- 1-4 bacilli +2- 5-10 bacilli +3- 10-20bacilli +4- more than 20

D/C drugs if the ff. are present: (HOT JAVA) Hearing impairment, Oliguria, Thrombocytopenia, Jaundice, Anemia, Visual Impairment, Albuminuria

bacilli Mantoux test (PPD) reading= after 48-72 hours >ID: 5-7mm diameter >5-9mm- cross reaction to other mycobacterial infection/ HIV >10 mm- positive >30mm or moresuggestive of secondary infection Chest X-ray= determines the extent of lesions

-before meals -Peripheral neuritis -Supplement w/ vit. B6 Pyrazinamide -admin. w/ meals -rapidly bacteriostatic and slowly bactericidal - hepatotoxic, nephrotoxic, inc. uric acid level, shoulder arthralgia -store in dark/amber colored container Ethambutol -give w/ meals -not give to children 8 y/o and younger -Optic Neuritis

DOTS: 5 elements S-upport M-icroscope A-nti TB drugs R-ecords T-reatment partner Maintain isolation no bronchial or back tapping proper sputum disposal high CHON diet

Class 0 > no exposure >not infected

Class 1 TB exposure (+)exposure (-) mantoux test (-) s/sx (-) x-ray

Category I New PTB/EPTB Seriously ill Aggressive/Intesive Phase: 2 months RIPE (fixcom-4, Myrin-P, Econokit) Maintenance Phase: 4 months RI Relapse Failure Cases

Streptomycin -given IM -can damage cranial nerve VIII Class 2 Class 3 Class 4 TB infection TB Disease TB inactive (+) exposure (+) history (+/-) previous (+) mantoux test (+) mantoux test chemotherapy (-) s/sx (+) s/sx (+) mantoux test (-) x-ray (+) sputum smear (-) s/sx (+) x-ray (-) sputum smear Category II Category III Category IV New PTB Chronic Not serious extra pulmonary Multi Drug Resistant Aggressive/Intesive Phase: 2 months RIPE Maintenance Phase: 4 months RI

Aggressive/Intesive Phase: 2 months RIPES then 1 month RIPE Maintenance Phase: 5 months RIE (fixcom-3, myrin, continukit)

Hepatitis Hepatitis A Other Names Causative Agent Mode of Transmission Source of Infection Incubation Period Onset Carrier Prognosis Infectious Hepatitis A Virus Fecal-oral Feces 2-6 weeks Acute None 1% Serum Hepatitis B Virus Blood and Body Fluids 6 weeks to 6 months Insidious Yes 2-10 % Hepatitis B Hepatitis C Post-Transfusion Hepatitis C Virus Blood transfusion and sex Blood and Body Fluids 5-8 weeks Sudden/gradual Yes No data

Symptoms: Pre-icteric- flu like symptoms, RUQ pain, malaise Icteric- jaundice, pruritus, acholic stool, RUQ pain, palpable liver, abdominal enlargement, CAPUT MEDUSA- dialted blood vessels of the abdomen Post-icteric- recovery period Diagnostic Test Liver function Test 1st- serum enzymes= SGPT (ALT), SGOT (AST) 2nd- total bilirubin Treatment: Symptomatic and Supportive Care Essential phospholipid/ Jetepar- syrup form Cholestyramine or Ursidiol Lamivudine (Zeffix)- inhibits replication of HBV Nursing Care Bed rest Isolation Diet- Low fat, high CHON, High CHO, high Calorie Encourage to eat sweets- ready supply of glucose NO- blood donation Oral care Clean and cut nails