Treatment Flashcards
Benign essential tremor
Beta blocker (propanalol)
Parkinson’s
Carbadopa and levodopa
Heart failure
ACE
BB
Diuretic
+/- hydralazine, nitro, dig
CHF in ED
LMNOP
Lasix Morphine Nitro Oxygen Position
Dilated cardiomyopathy
Same as CHF
ACE, diuretic, +/- BB
Restrictive Cardiomyopathy
Tx cause
Amyloidosis (MC)
Sarcoidosis
Hemachromatosis
HOCM
BB
CCB
Disopyramide
EtOH ablation
AICD surgery
Avoid dehydration and extreme exertion
Infective endocarditis
Vancomycin and Gentamycin unless fungal (ampho)
Pericarditis
Med: NSAIDS, aspirin, colchicine
Steroids if refractory
Pericarcial effusion
Pericarcial centesis
Constructive pericarditis
Pericardectomy
Pulmonary Htn
CCB
Viagra
Prostocyclins
CMV
Neonates (neurological, hearing loss)
Aids (blindness)
Serololgy, PCR tissue bx (AIDS)
Supportive AIDS
Oral valgancyclovir for sereve
EBV
Fever, malaise, pharyngitis, rash, spenomegally
Post cervical nodes
Atypical lymph
Monospot (25% false neg in first week)
Positive IgM
Supportive
Avoid contact sports
Rheumatic fever
Carditis Polyarthritis Sydenham chorea Erythema marginatum Subq nodules
Fever Arthralgia Previous RF Elevated APRs Prolonged pr
NSAIDS, antibiotics
Propholaxis: benzathine PNC monthly for 10 years
TB
Positive ppd
5mm if immunosupressed
10mm CKD, healthcare
15mm all others
Rabies
PEP:
No vaccine, give IG and vaccine
Previous vaccine, give vaccine
Munmps
Orchids
Parotid enlargement
MENINGITIS
Live virus vaccine
HIV
HIV 1,2 Ab and HIV p24 g
If positive NAT
If reactive confirm with western blot
Rheumatic fever
Group A beta strep
Mitral valve
Jones criteria: carditis, poly arthritis, nodules, Erythema marginatum
Fever, Arthralgia, previous infection, APRs elevated, prolonged or
NSAIDS, antibiotics
Ppx, benzathine pnc monthly 10 yr or are 40
TB drugs
Isoniazid, peripheral neuropathy (give b6)
Rifampin, orange secretions
Pryazinamide, GI/muscle joint pain
Ethambutol, optic neuritis (red-green loss)
MAC
AIDS pts
fever, wt. loss anorexia, diarrhea
Azithro, clarithro, rifabutin, Ethambutol
Leporacy
Rifampin, dapasone, clofazimine
Cholera
Still culture
Doxy, aggressive rehydration
G and C
NAAT of urine
250 mg ceftriaxone, 2 g azithro
Salmanella
Pea soup
Typhi causes constipation
Rose spots on trunk
Still culture
Fluids, K, cipro, ceftriaxone
Shigella
Daycare
Bloody diarrhea
Stool culture
Cipro
Botulism
Diplopia, dry mouth, dysphagia, dysphonia
Descending paralysis, fixed dilated pupils
Hypotonicity
Clinical
Anti toxin A, B, E (w,e,n)
Tetanus
IG and vaccine if bad wound and never or under vaccinated
Only vaccine if minor wound
Lyme
Summer
Bullseye
Flu like sx
Arthritis and muscle pain, Neuro sx bell’s pausey
Disseminated
Doxy
ceftriaxone or pnc g in Neuro disease
RMSF
Fever, myalgia
Petechial or purpuric palms and soles
Leukocytosis, proteinuria, hematuria, thrombocytopenia
Sero test (difa)
Doxy (even in kids)
Syphilis
Torch
Chancre
VLDR
Rash on plans and soles, condylomata lata, argyll-robertson pupils, tabes dorsalis
Late stage: aortitis, aneurysms, aortic regurg
Cryptococcosis
Cryptococcus neoformans
Immuno compromised
H/A, AMS, meningitis
India ink prep
Fluconozole or ampho for neuro
Histoplasmosis
Most patients asymptomatic
Ranges from flu-like symptoms to multi-organ disease mediastinitis, eye, CNS
RIA, DNA probes
Cxr: military pattern
Itraconazole
Ampho
Pneumocystis Jiroveci
Fever, dyspnea, non-productive cough
Bilateral Interstitial disease without Hilary adenopathy
Low O2, gallium uptake, tissue stains via bronch
Bactrim
Hookworms
Southeast Tunneling GI bleed, blood tinged sputum Guac positive O and p
Pyrantel, albendazol
Round worms
Contaminated soil
GI distention
Albendazole
Whip worm
Prolapse
O and p
Pinworms
Scotch tape
Malaria
Recurring fever, chills, spenomegally
Parasites on red blood smear
Falciparum is continuous, cerebral, and Blackwater fever
Atovaquone
Doxy, ppx
Toxoplasmosis
Immuno supressed
Strep-like
Serololgy Ct scan (ring enhancing lesions)
Pyrimethamine and sulfadiazine
Fibromyalgia
Tylenol, NSAIDS, exercise, ssri, sleep
Gout
Uric acid crystals
Negative birefrengence
Indomethacin, colchicine
Allopurinol for ppx
Probenacid if not tolerated
Pseudo gout
Cpp crystals
Positive birefrengence
Indomethacin, colchecine
PMR
Multiple joint stiffness, shoulder often first
Elevated ESR often >100
Must evaluate for temporal arthritis!
H/A, elevated ESR, temples ttp, pain in jaw, vision changes
Temporal artery bx
Tx both with steroids
Reactive arthritis
Joint pain following a respiratory or GI infection
Chlamydia, campylobacter, shigella, salmonella, and yersenia
Uveitis, urethritis, arthritis
Balantitis, keratoderma
Elevated ESR and CRP
Tx cause NSAIDS Steroids DMARDs Optho referral
Rheumatoid arthritis
Methotrexate
Antimalarials
Biologics
SLE
Joint pain, swelling
Fever, wt. Loss, fatigue
Mylar rash, discord rash, mucosal ulcerations, Alopecia, officer is, raynauds, livedo reticularis, Raynauds
ANA non specific
Hydroxychloroquinine
Methotrexate
Steroids
Sjhogrens
Dry sx
Salivary gland bx
Manage sx
Tension H/A
Ibuprofen, NSAIDS, caffeine, Tylenol
Amitryptylene, ssri, anti convusant
Migraines
NSAIDS, tylenol, tryptans, antiemetics
BB, CCB, ace/arb, dhe, dexamethasone
Cluster H/A
Severe pain, unilateral, ocular as, trigeminal neuralgia
High flow O2
Triptans
Verapamil, low dose prednisone
TIA
Stroke workup
Carotid endartectomy
Anti-platelet for 90 days
Risk factor reduction
Ischemic stroke
Stroke workup
Tpa within 4.5 hr
Thrombectomy within 6 to 24 hrs
Carotid endartectomy
Anti-platelet for 90 days
Risk factor reduction
Sub arachnoid hemmorage
Manage bp, reverse anticoag, shunt, clip anneurism, nimodipine
Bacterial meningitis
Pathogen directed antibiotics
Acyclovir
Acyclovir if HSV encephalitis
Benign and self-limited
Huntington disese
No cure, tx movement with terabenzanine and other neuroleptics
Fatal in 15-20 yrs
Parkinsons
Levodopa/carbadopa
Amantafine, benzotropine, COMT inhibitors
Seizure
Valproate, carbamazapine (CI in pregnancy)
Focal neuropaty
Activity modification
Anti-inflamatories, steroids
Cerebral pausey
Supportive, may sulfate in preterm labor
Concussion
Remove from activity, full exam, monitor 24 h, tx sx, admit GCS <15, a normal CT, seizures
Remember 2nd impact syndrome
Dementia
All types acetylcholine esterase inhibitors
AD: N-methyl-D aspartic acid and vit E
Lewy Body: dopamine agonist
Vascular: controlled BP
Delerium
Tx conservatively
Altered level of Consciousnee
ABC, monitor, tx cause
GBS
Immune-mediated demylienation
Ascending paralysis
In pt.
Plasma pharesis, IV If, monitor
MS
Relapsing remiting: high dose steroids
Primary progressive
Secondary progressive
Disease mod agents: glatiramir, fingolimod, natilizumab (multifocal leukoencephalopathy)
Tourette
Pt. Ed
Dopamine agonist (fluphenazine, pimozidel
Botox
Syncope
Tx. Directed at cause
Presbycusis
Age related hearing loss
High frequency
Hearing aids
Noise induced SNHL
Notched audiogram
Acoustic neuroma
Slow growing benign tumor CN 8
Unilateral loss, balance, tinnitus
Surgery, radiation
Sudden SNHL
Occurs within 72 hrs
Dizziness, fullness, vertigo
Emergency
Labrinthitis
Autoimmune
Vascular
Prednisone
External auditory canal foreign body
Remove if possible to get on the first try
Consult ENT if perf or touching TM
Don’t remove batteries
Articular hematoma
ID
Otitis externa
Topical AB
ciprodex
OE fungal
Very itchy
Suspect if refractory to AB
Acetic acid drops
Clotrimazole dropsa
Malignant OE
ENT emergency
Austrian tube disfunction
Nasal steroids
OM with effusion
Nasal steroids
Tubes
AOM
Amoxicillin
Macrolide in PN allergic or Bactrim
Mastoiditis
Emergency
AB and surgery
Cholesteatoma
Retraction pocket of following perf
Surgical excision
TM perf
Non ototoxic ear drops (quinilones)
Keep dry
Check in 1-2 months
Tympanoplasty
Bullous myringitis
Mycoplasma, H flu, step pneumo
Macrolide clarithro
Maybe opiates
Otosclerosis
Shapes fuse to TM
Stapedectomy
Hearing aids
Tinnitus
Pt. Education
Background noise
Avoid caffeine/nicotine
Meinerers disease
Increased endolymphatic pressure
SNL hearing loss
Diuretics, restrict Na, meclizine surgery
Labyrinthitis
Vertigo lasting days, imbalance for weeks
Tx with meclizine or diazepam, if SNL steroids
Nasal FB
Remove, tx infection if present
Nasal vestibulitis
Infection of nasal hair follicles
Bactroban, keflex, found a, amox
Nasal mucositis
Saline nasal spray and, TOPICAL AB
Epistaxis
Ant. Kesselbachs
Posterior, woodruffs
Manual compression
Afrin
Cautery (anesthetized, decongest, TOPICAL AB)
Cocaine
Allergic rhynitis
IgE mediated
Nasal steroids
Antihistamines
Leukotriene inhibitors
Nasal polyposis
Surgical if obstructive
Samters triad: sinusitis, asthma, polyps
Avoid asprin
Vasomotor rhynitis
Similar tx as allergic
Rhinitis medicamentosa
Stop attending agent, switch to steroids
Viral rhinitis
Supportive
Chronic sinusitis
Consider structural abnormality
Viral pharyngitis
Tx supportive with OTC meds
Strep pharyngitis
Amoxicillin, pen VK, augmentin
Azithro, clinda
Acute tonsilitis
If bacterial AB, if viral supportive
Peritonsillar abcess
ID, amoxicillin or clinda
Parotitis and siladenitis
Tx cause
Sialogoues and warm compresses
Sialolithiasis
Sialogoues, tx with surgery if obstructive
Oral candidiasis
Oral nystatin 5cc swish and swallow qid
Fluconazole
Squamous papilloma
Caused by HPV
Can become squamous cell
Biopsy
Leukoplakia
Precancerous
Bx
Monitor
Smoking cessation
Aphthous ulcers
Benign and self limiting
Oral herpes simplex
Tx antivirals within 72 hrs
Acute laryngitis
Tx with voice rest and fluids, smoking cessation
Essential Hypertension
Goal >150/90 for >60
Goal <140/90 all others <60 (CVD, diabetes)
Non black
Thiazide, ace or arb, CCB
Black
Thiazide, CCB
Renal (Ace or ARB)
Hypertensive urgency
BP > 180/120 with no target organ damage
Reduce 25% over several hours with labetelol, clonidine, nitrates, hydralizine
Hypertensive emergency
BP >180/120 with target organ damage
Papilledema, neuropathy, seizures, AMS
Gradual reduce 10% 1hr and 15% over 3-12 no less than 160/110 with IV nitropruaside, hydralazine, nitro, nicardipine
Metabolic syndrome
Waste circumfrence Htn FBG >110 HDL<40 in men and <50 in women Tri >150
Need 3 or more
Stable angina
Exertional
Normal ekg
Releived with nitro
Unstable angina
At rest
Lasts longer than stable
Not as well controlled with nitro
Aspirin, BB, statin
Also use these meds with stable angina
NSTEMI
cardiac enzymes not elevated
ST depression, T wave inversion, possible Q waves
Possible stent
Aspirin and plavix, BB, CCB, ace, statin, nitro
STEMI
Elevated enzymes and ST elevation
PCI <3h from sx onset and 90 mins from door to balloon
Plavix, aspirin, statin, BB, CCB, ACE, Nitro
Types of MI
RCA: Inferior: II, III, AVF LCA: Lat: I AVL, V5-V6 LAD: Ant: V2-V4 RCA: Post: VI-V2 LAD: Ant lat: V2-V6
Prinzmetal Angina
CCB avoid BB
Possible stent
AAA
Surgical repair if >5.5 or cm per yr, sx, or rupture
TAA
Surgical repair if >5.5, cm / yr or 4.5-5 if ED or Marfans
Aortic dissection
DeBakey I: to aortic arch (<65 y/o) DeBakey II: confined to ascending aorta DeBakey III: descending (elderly) Stanford A is ascending (surgery) Stanford B is descending (meds)
Tx with surgery (tube graft)
PAD
Asprin +- plavix, statin, BB, ace
ABI<0.9
Doplar
Angiography is gold standard
Arterial exclusive disease
Pain, Palos, pulslessness, poikilothermia, paralysis
CTA, doplar, MRA
Thrombectomy, thrombolytic, stent
Varicose veuns
Compression hose, tx ulcers, ablation, sclerotherapy, vein stripping
Phlebitis
NSAIDS, warm compresses, extremity elevation
DVT
Ultrasound
Anticoagulate for 3 months lovenox, warfarin, xarelto, elequis
PE
Spiral CT
Pulm angiography GS
S1Q3T3 for for pulmonale
Anticoag >3 months lovenox, warfarin, xarelto, elequis
IVC filter if unable to tolerate
Esophagitis
Candida, GERD, pill, radiation
EGD
Tx cause
Achalasia
Loss of ganglion cells in Auerbach plexus
Dysphagia And regurg of non-digested, non-acidic food
Birds been on barium swallow
Dilation, botox, esophagotomy
Esophageal Strictures
Schatzkis ring Zenkers diverticulum (proximal esophagus) aspiration Esophageal web (Plummer Vincent syndrome) DIGS
All dx with egd and barium swallow
All tx with soft diet and dilation
Esophageal cancer
Upper 2/3 of esophagus squamous cell
Smoking and EtOH
Lower 1/3
Adenocarcenoma
EGD and bx
Surgery, chemo, rad
Barrett esophagus
Long standing GERD
40x increase in esophageal cancer
Mallorie weis tear
Superficial esophageal tear
Painless hematemisis
Self limiting, aged w/thermal coag
Boerhaaves Syndrome
Esophageal rupture from forceful vomiting or instrumentation
Emergency
Hammans crunch
Widening of the mediastinum with free air
Anti-emetics, abx, surgery
Esophageal varacies
Dilated esophageal veins
30% bleed, 30% of those die
Bright red upper GI bleed, +/- melna, hypotension, instability
Emergent fluids, sleep therapy, banding
GERD
Antacid
H2
PPI
Gastritis
Stop offending agent
EGD with biopsy, h pylori testing
Antacid, H2, PPI
Peptic ulcer disease
H pylori, NSAIDS, secretions issues
Duodenal 5× more likely
H pylori
Clarithro, amox, and ppi
GI cancer
Adenocarcinoma
Virchow node (supraclavicular)
Sister Mary Joseph’s nodule (periumbilical)
EGD w/biopsy, ct, resection, rads chemo
Pylori stenosis
Greater in males
3wk-5mo
Non-bilious vomiting
Palpable olive mass
U/S and surgery
Gallbladder
Charcots triad: jaundice, fever, pain
Reynolds pentad: above plus hypotension and AMS (septic cholangitis)
Corvoisier sign painless jaundice and large palpable non-tender GB (cancer at head of pancreas)
Boas sign pain radiating to tip of right scapula
Tx Cholecystectomy, ERCP
Pancreatitis
Acute: EtOH, gallstones
Chronic: EtOH
Cullens sign: periumbilicall echimosis
Grey-Turner’s sign: flank echimosis
Lipase>300
Bowl rest, fluids, pain met, NPO
Random criteria estimates mortality
Pancreatic cancer
CT, u/s with fnb
Surgery whipple, chemo, rad
Bad prognosis 1 yr 20% 5 yr 7%
Vit. A def
Elderly, alcoholics
Night-blindness, dry skin, poor wound healing
Vitamin B1 (thiamine)
Alcoholics, poor
Wernickes encephalopathy
Korsakoff syndrome
Beriberi (wet-dry)
Vitamin B3 (niacin) def
Pellagra
3Ds: diarrhea, dermatitis, and dementia
Vitamin B12 (coblamin) def
Elderly, vegans, atrophied gastritis
Vitamin C def
EtOH and elderly
Scurvy
Bleeding gums, Petechia, poor healing
Vitamin D def
Elderly, women, renal, low sun light, and infants
Ricketts and osteomalacia
Vit K def
Increased bleeding, increased prothrombin time PT
Phenylketonuria
Screened at birth
Enzyme that metabolized protein
Tx by reducing protein
A flutter
Stable: vagle, BB, CCB
Unstable: SCV
Definitive: ablation
A fibb
Stable: BB, CCB, dig, anticoag
Unstable: SCV if new if not anti cost for 3 weeks before
Definitive ablation
SVT
Stable: adenosine, BB, CCB
Wide complex: amioderone
Unstable: SCV
Def: ablation
WPW
Delta waves This is wide complex: procanimide AVOID! Adenosine, BB, CCB, and dig Unstable: SCV Definitive: ablation
V tach
R on T
Hypokalemia, hypomag, antiarrhthmic, prolonged QT
Stable: this is wide complex, so amioderone
Unstable with pulse: SCV
Polymorphic (torsades): mag
Unstable no pulse: defib and CPR
Vfib
Unsyncronized CV
2nd degree AV block
Type 1 wenkebach
Going drop
Type 2
sustained prolonged PR with drop
Tx with atrophied if sx brady
1st degree AV block
Prolonged PR>0.2 s
Atropine if sx brady
Third degree AV block
Transcutaneous pacing
Perm pace for definitive
LBBB
Broad R in v5, v6
Deep S in v1, v2
RBBB
RSR in v1, v2
Deep S in v5, v6
Ekg right vent hypertrophy
R>7mm or positive in v1
Ekg LVH
Add S in v1 or 2 to R in v5 or v6
>35 men or 30 women dx
Blephritis
Baby shampoo, TOPICAL ab
Ectropion
Eyelids roll out
treatment is surgery
Entropion
Eyelids roll inward
Treatment is surgery
Chalazion
Blocked memobian gland
Warm compress, elective removal
Hordoleum
Painful
Caused by staff infection
Ab, id
Dacrocystitis
Infection of the lacrimal sac secondary to staph, strep, staph epidermidis, Candida
Pterygium
No treatment unless blocking vision
Pinguecula
Benign yellow Mass on the conjunctiva
Allergic conjunctivitis
Topical antihistamine drops, oral antihistamines
Viral conjunctivitis
Adenovirus
Warm compresses, artificial tears, topical antibiotics?
Bacterial conjunctivitis
Topical antibiotics or oral antibiotics for G / C conjunctivitis
HSV conjunctivitis
Dendritic ulcers on cornea
Most common cause of corneal blindness
Hutchinson’s sign is HSV on tip of nose
Topical or oral antivirals
Iritis
Limbic flush: erythema goes to edge of iris
Treat with steroids and dilating drops
Corneal abrasion
Treat with topical antibiotics to cover pseudomonas
Do not give tetracaine or topical anesthetic
Corneal ulcer
Immediate referral to Ophthalmology
Cataracts
Lens replacement surgery
Closed angle glaucoma
Immediate referral to Ophthalmology
Topical beta blockers and IV acetazolamide
Open-angle glaucoma
Progressive vision loss
Treat with prostaglandins, beta blockers, Alpha Agonist, Carbonic anhydrase inhibitors
Hyphema
Leading into the anterior chamber
Treat by elevating head of bed, reducing IOP, reversing coagulation issues, possible surgery
Macular degeneration
Most common cause of blindness in age over 50
No true eatment
Papilledema
Evidence of increased intracranial pressure
Suspect CNS tumor, intracranial hypertension, ventricular system obstruction
Retinal detachment
Acute painless vision changes
Increased floaters, flashes, curtain
Laser cryosurgery
Patient lies with head to the affected side
Central retinal artery occlusion
Emergent referral to Ophthalmology
Central retinal vein
Thrombotic event
Sudden painless unilateral vision loss
Blood and Thunder
Can recover with time
Retinopathy
Hypertensive: AV nicking, cotton wool spots
Diabetic: hard exudates, edema, microaneurysms, venous dilation
Treat underlying disease
Orbital blowout fracture
Diplopia and exophthalmos
Entrapment can lead to diminished EOM in downward gaze
Observation if non-displaced fracture with normal extraocular movements
Surgery
Penetrating eye trauma
Seidel sign: leaking Fluorescein, open globe
Shield eye
Immediate referral to opthamology
Orbital cellulitis
Broad-spectrum antibiotics
Horizontal nystagmus
Vestibular disorder
Vertical nystagmus
Central nervous system disorder
Optic neuritis
Multiple sclerosis!
Pain with arm movements, color vision alteration
MRI with contrast is highly sensitive
IV steroids speed recovery
Strabismus
Misalignment of the eyes
Evident with corneal light reflex
Treat with exercises or surgery
Amblyopia
Ocular pathology interfering with normal cortical visual development
Visual Center in the brain won’t develop and will never learn to see what then I
Can be caused by strabismus most common
Treat with early corrective lenses and patching
Vision loss permanent if left untreated
Amblyopia
Ocular pathology interfering with normal cortical visual development
Visual Center in the brain won’t develop and will never learn to see what then I
Can be caused by strabismus most common
Treat with early corrective lenses and patching
Vision loss permanent if left untreated
Graves disease
Autoimmune hypertyroid
TSH low
T4 high
TSI positive
Radioactive iodine
Meds if pregnant (polythiouracil 1st trim) methimazole after
Hashimotos
Autoimmune hypothyroidism most common
Elevated TSH
Postitive tpo
Levothyroxine
Subacute thyroiditis (dequervians)
Painful goiter, transient hyperthyroidism, follows viral infection
Tx as with BB, NSAIDS, and levothyroxine
Primary hyperparathyroidism
Elevated serum Ca
Elevated PTH
Decreased phos
Bones, stones, groans, moans, psych overtones
Osteoporosis, kidney stones, constipation, muscle spasms, depression and personality d/o
Parathyroidectomy
Hypoparathyroidism
Surgical MC
Parasthesias, laryngeal spasm, prolonged QT
Low calcium, low pth, high phos
Calcium supplementation and vit D
Addisons
Fatigue, wt. Loss, hypotension, dry skin
Decreased sodium
Increased K
Hypoglycemia
Hypochloremia
Increased skin pigment due to ACTH
21 hydroxylase ab most specific
With adrenal cortex ab almost 99%
24 urine cortisol first test to r/o
ACTH st in test GS
Tx w/steroids
Cushings
Excessive ACTH producing pituitary awesome MC
Dexamethasone suppression test (ACTH and cortisol can be supressed)
Adrenal adenoma decreased ACTH, increased cortisol can’t be suppressed with dexamethasone
Ectopic ACTH both elevates and aren’t suppressed
24th urine cortisol, salivary test
Surgery to remove tumor
Acromegally
Pre puperty: gigantism
Post puberty: acromegally
Headache MC secondary sx, Arthralgia and myalgias
GH producing pituitary tumor
IGF and GH elevated
OGTT is GS (if suppressed, no acromegally)
Dopamine agonist (cabergoline) or surgery
Dwarfism
Decreased IGF and insulin like binding protein
Dx with GH st in test with arginine and clonidine
GH shots
Prolactinoma
Most common neoplasm in MEN-1
Galactorhhea (women)
Gynochamastia (men), decreased libido
Cabergoline
Ventral DI
Caused by trauma
Politics, polydipsia
Low urine osmolariy, high serum Na, high serum similarity, low urine SG
Desmopressin
Cervical lesions
LSIL with neg pap repeat in 1 yr
LSIS with no or positive pap: culpo and bx
PMDD
4 depression sx for pms
5 for PMDD
Gonnorhhea cervicitis
Rocephin 250 mg IM
Chlamidya
Azithomycin 1 g
Trichamonas
Flagyl
HSV cervicitis
Acyclovir
