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Conjunction test
Quiz by Анара Серикова
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1. I was ill .......................... I didn't go to work.
as
because
so
2. You should get your license renewed at once ................... pay a fine.
nor
or
but
1. I was ill .......................... I didn't go to work.
2. You should get your license renewed at once ................... pay a fine.
3.I am very tired ................................ I have been working all day.
4.She not only gave us a fine dinner ......................... drove us back home.
5.I am not angry. ............................. anything I feel a little surprised.
6.Shy people speak less, ________ they can speak when triggered.
7.________________ he claims that he is innocent, everyone knows he is guilty
8.________________ you're here, I'm going to tell you a secret.
9. ________________ you like him personally, you have to agree that he's done a lot for the company.
10.______________ I prefer to live in an apartment, my wife wants to buy a house.
Pre-test ConjunctionChapter 22 Antihypertensive Drugs Hypertension Defined (JNC-8) Pharmacology Overview 7 main categories of drugs to treat HTN Adrenergic drugs (old friend) Angiotensin-converting enzyme (ACE) inhibitors Angiotensin II receptor blockers (ARBs) Calcium channel blockers (CCBs) Diuretics Vasodilators Direct renin inhibitors A. Adrenergic Drugs: 5 Subcategories and where they act A1. Adrenergic neuron blockers (central and peripheral)- we won’t talk about this A2. Alpha1 receptor blockers (peripheral) A3. Alpha2 receptor agonists (central) A4. Beta receptor blockers (peripheral) A5. Combined α and β receptor blockers (peripheral) A2. Peripherally Acting Adrenergic Drug Alpha1 Blockers (we’ve met these) Doxazosin, prazosin, alfuzosin Block alpha1-receptors which causes BP to decrease Reduces peripheral vascular resistance and BP by dilating both arterial and venous blood vessels Main Use: benign prostatic hyperplasia (BPH) Alpha1 Blockers REMEMBER Tamsulosin (Flomax)* is an α1 blocker BUT *Tamsulosin is not used to control BP, just for BPH. A3. Centrally Acting Adrenergic Drugs Alpha 2 agonist Clonidine and methyldopa 1- Stimulate alpha2-adrenergic receptors. in the brain Decreases sympathetic outflow from the CNS which decreases NE production 2. Stimulate alpha2-adrenergic receptors in kidneys remember alpha 2 opposes alpha 1 Dilates peripheral blood vessels → lowers peripheral resistance → Results in decreased BP So ….Clonidine (Catapres) Used primarily for its ability to decrease blood pressure in an urgent setting Also use in opioid withdrawal as previously discussed Oral (multiple times a day), and topical patch formulations Do not stop abruptly as it may lead to rebound hypertension In reality, Clonidine and methyldopa Not prescribed as first-line home antiHTN drugs High incidence of unwanted adverse effects: orthostatic hypotension, fatigue, and dizziness MIGHT be uses as adjunct drugs after other drugs have failed, in conjunction with other antiHTN such as diuretics A4. Adrenergic Drugs Selective Beta 1 Blockers Metoprolol, Atenolol Reduction of HR through β1 receptor blockade (remember adrenergic blocking of this receptor???) HR results in BP Cause reduced secretion of renin = BP A4. Adrenergic Drugs Selective Beta1 Blockers Nebivolol (Bystolic) Uses: hypertension and HF Action: blocks β1 receptors and produces vasodilatation, which results in a decrease in SVR High doses loses selectivity and blocks both β1 and β2 Less sexual dysfunction All BB- Do not stop abruptly; must be tapered over 1 to 2 weeks A4. Adrenergic Drugs NONSelective Beta Blockers Propranolol Acts equally on β1 and β2 Other uses include situational anxiety associated with public speaking, test taking As mentioned on previous slide, nebivolol at high doses becomes beta nonselective A5. Dual-Action Adrenergic Drugs α1 and β Receptor Blockers Dual antihypertensive effects of reduction in heart rate (beta1 receptor blockade) and vasodilation (alpha1 receptor blockade) Examples are carvedilol (common) and labetalol (not as common) A5. Dual-Action Adrenergic Drugs α1 and β Receptor Blockers Carvedilol (Coreg) Widely used drug that is well tolerated Uses: HTN, mild to moderate HF in conjunction with digoxin, diuretics, and ACE inhibitors Contraindications: severe bradycardia or unstable HF, bronchospastic conditions such as asthma, and various cardiac conduction problems Adrenergic Drugs Indications - HTN But also for Glaucoma (topical) BPH: doxazosin, prazosin, and terazosin (2 for 1) Management of severe HF when used with cardiac glycosides and diuretics Contraindications Acute HF- have to stabilize first MOAIs- yeah doesn’t everything interact with MAOIs? Peptic ulcers Severe liver/kidney disease Asthma (with beta blockers) Adrenergic Drugs: Adverse Effects Orthostatic hypotension 1st-dose syncope Rebound hypertension with abrupt discontinuation Most common: Dry mouth, drowsiness, constipation, sedation Interactions- always check for specific drug interactions Can cause additive CNS depression with alcohol, benzodiazepines, opioids Question #1 When administering an alpha-adrenergic drug for hypertension, it is most important for the nurse to assess the patient for the development of what response? Hypotension Hyperkalemia Oliguria Respiratory distress Answer A Hypotension This is a key point in patient education These drugs have strong vasodilating properties and may cause severe hypotension, especially at the beginning of therapy. B. Angiotensin-Converting Enzyme Inhibitors aka ACE Inhibitors or ACEi Large group of safe and effective drugs Currently are 10 ACEi Often used as first-line drugs for HF and hypertension May be combined with a thiazide diuretic, loop diuretic, or Calcium Channel Blocker (CCB) You need to understand the basics ACE Inhibitors: Review RAAS ACE converts angiotensin I, formed through the action of renin, to angiotensin II Angiotensin 2 is a potent vasoconstrictor and also induces aldosterone secretion by the adrenal glands Aldosterone stimulates sodium resorption (H20 follows Na Both act to raise BP which causes kidneys to reduce renin production ACEi= Great drug to treat HTN BUT contraindicated in pregnancy (2nd,3rd trimester due to fetal renal damage) and breastfeeding first few weeks after birth B. ACE Inhibitors - PRIL Lisinopril (Prinivil) super common, often the 1st drug Enalapril (Vasotec) also common Captopril (Capoten) great if liver disease present Benazepril (Lotensin) Fosinopril (Monopril) Perindopril (Aceon) Quinapril (Accupril) Ramipril (Altace) Trandolapril (Mavik) Primary Effects of the ACE Inhibitors Prevent Na (and H2O) resorption by inhibiting aldosterone secretion (volume reduction) (GO BACK TO RAAS DIAGRAM) blood volume decreases work of the heart preload, or the left ventricular end-diastolic volume which is important in HF ACE SUMMARY OF ACTIVITY 1) Prevent vasoconstriction caused by angiotensin 2 (2) Prevent aldosterone secretion less sodium and water resorption Cardioprotective Effects of ACEi They slow progression of left ventricular hypertrophy (ventricular remodeling) after MI so considered cardioprotective ACE inhibitors have been shown to decrease morbidity and mortality in patients with HF Renal Protective Effects of ACEi ACE inhibitors: reduce glomerular filtration pressure by volume reduction Cardiovascular drug of choice for patients with diabetes since it helps protect kidneys by reducing pressure. Sometimes used low dose for kidney protection with DM without HTN B. ACEi Enalapril (Vasotec) Only ACEi available in both oral and IV Enalapril IV does not require cardiac monitoring Oral enalapril: prodrug (metabolized in liver) Improves patient’s chances of survival after an MI Reduces the incidence of HF B. ACEi Captopril (Capoten) Uses: prevention of ventricular remodeling after MI; reduce the risk of HF after MI Shortest half-life Must be administered multiple times throughout the day so this limits its use Not a prodrug so good for patient with liver disease Question #2 A patient with diabetes has a new prescription for the ACE inhibitor lisinopril. She questions this order because her provider has never told her that she has hypertension. What is the best explanation for this order? The doctor knows best The patient is confused This medication has cardioprotective properties This medication has a protective effect on the kidneys for patients with diabetes Answer D ACE inhibitors have been shown to have a protective effect on the kidneys because they reduce glomerular filtration pressure. This property makes them the cardiovascular drug of choice for patients with diabetes. Question #3 A patient with a history of pancreatitis and cirrhosis is also being treated for hypertension. Which drug will most likely be ordered for this patient? Clonidine Prazosin Diltiazem Captopril Answer D Captopril Captopril is not a prodrug; therefore, it does not need to be metabolized by the liver to be effective. This is an advantage in patients with liver disease. ACE Inhibitors: Adverse Effects *Dry, nonproductive cough, which reverses when therapy is stopped. This is a class effect Dizziness- Note: First-dose hypotensive effect may occur Headache & Fatigue Possible hyperkalemia ** Angioedema: rare but potentially fatal Not safe in pregnancy-are contraindicated during the second and third trimesters of pregnancy because of increased risk of fetal renal damage C. Angiotensin II Receptor Blockers (ARB) Considered an alternative to ACEi Less likely to cause a dry cough and hyper K+ that is common with ACE inhibitors Angiotensin II Receptor Blockers: Mechanism of Action Go back to RAAS diagram! ARBs affect primarily 2 places 1. Vascular smooth muscle - blocks vasoconstriction 2. Adrenal gland -Selectively blocks the binding of Ang 2 to certain Ang 2 receptors inhibiting secretion of aldosterone Lowers volume retention and BP Angiotensin II Receptor Blockers -ARTAN Losartan (Cozaar)- very common Eprosartan (Teveten) Valsartan (Diovan) Irbesartan (Avapro) Candesartan (Atacand) Olmesartan (Benicar) Telmisartan (Micardis) Azilsartan (Edarbi) C. ARB Losartan (Cozaar) Beneficial in patients with HTN and HF Used with caution in patients with kidney or liver dysfunction and in patients with renal artery stenosis ***Not safe for breastfeeding women and should not be used in pregnancy (Cat C 1st trimester, Cat D 2nd-3rd trimester), potential fetal toxicity Appear to be equally effective for the treatment of hypertension and well tolerated ARBs less likely to cause cough and hyperK+ but can still happen Evidence that ARBs are associated with lower mortality after MI than ACE inhibitors Never take ACEi and ARBs at the same time* 5. Calcium Channel Blockers (CCB) Primary use: HTN, angina, some dysrhythmias Cause smooth muscle relaxation by blocking the binding of calcium to its receptors, preventing muscle contraction Results in: Relaxed blood vessels to the heart Decreased peripheral smooth muscle tone Decreased SVResistance Decreased BP E. Diuretics First-line antiHTN in JNC 8 guidelines Decreases fluid volume The results from diuresis: preload, Peripheral resistance Overall effect Decreased workload of the heart and decreased BP Thiazide diuretics are the most commonly used diuretics for HTN Ie hydrochlorothiazide (HCTZ), chlorthalidone We will discuss diuretics further in the chapter on diuretics F. Vasodilators Directly relax arterial or venous smooth muscle (or both) Results in: Decreased SVR Decreased afterload Peripheral vasodilation Indicated for treatment of HTN May be used in combination with other drugs F. Vasodilators Hydralazine (Apresoline) Orally: routine cases of essential hypertension Injectable: hypertensive emergencies BiDil: specifically indicated as an adjunct for treatment of HF in African-American patients F. Vasodilators Sodium Nitroprusside (Nitropress) *Sodium nitroprusside and IV diazoxide are reserved for the management of hypertensive emergencies. Contraindications: severe HF, known inadequate cerebral perfusion (especially during neurosurgical procedures) F. Vasodilators Adverse Effects Hydralazine: dizziness, headache, tachycardia, edema, dyspnea, N/V/D, vitamin B6 deficiency, rash Sodium nitroprusside: hypotension, bradycardia, decreased platelet aggregation, rash G. Direct Renin Inhibitors Aliskirin (Tekturna) Blocks the RAS pathway at the point of activation. Inhibiting renin production prevents the downstream production of Ang II (potent vasoconstrictor) Adverse effects: N/V, severe hypotension, hyponatremia, hyperkalemia… Contraindicated in patients with DM taking ACEi or ARB Miscellaneous Antihypertensives Eplerenone (Inspra) Newer class of drugs called selective aldosterone blockers (remember RAAS?) Reduces BP by blocking the actions of aldosterone at its corresponding receptors in the kidney, heart, blood vessels, and brain Indications: routine treatment of hypertension and for post-MI HF Contraindicated if serum potassium levels are high (above 5.6 mEq/L) A Special Form of HTN Treatment of Pulmonary Hypertension Sildenafil and Tadalafil Commonly used for erectile dysfunction Used for pulmonary hypertension but with different trade names Sildenafil: Revatio* (Viagra for ED) Tadalafil: Adcirca* (Cialis for ED)Oral Manifestations of Viral Infections Viral infections can lead to a variety of oral manifestations, which may vary depending on the type of virus involved. Below are the key viral infections and their associated oral symptoms. --- 1. Herpes Simplex Virus (HSV) Infections Type: HSV-1 and HSV-2 Common Oral Manifestations: Primary Herpetic Gingivostomatitis: In children, presents as painful swelling and redness of the gums, with vesicular lesions on the lips, tongue, and hard palate. Recurrent Herpes Simplex: Cold sores (herpes labialis) often appear on the lips or around the mouth, and are painful and fluid-filled. Herpetic Whitlow: Infection of the fingers, often seen in healthcare workers. Clinical Features: Vesicular lesions that break to form ulcers Painful and burning sensations in affected areas Swollen lymph nodes Fever (during primary infection) Diagnosis: Direct immunofluorescence, PCR, or viral culture. --- 2. Varicella-Zoster Virus (VZV) Infections Type: Varicella (chickenpox) and Herpes Zoster (shingles) Common Oral Manifestations: Varicella: Enanthem (oral lesions) such as vesicular lesions on the hard palate, tongue, and lips, in conjunction with the characteristic skin rash. Herpes Zoster (Shingles): Unilateral painful oral lesions, often involving the hard and soft palate, and can extend to the tongue or buccal mucosa along the distribution of the trigeminal nerve. Clinical Features: Vesicular lesions that ulcerate Pain and discomfort in affected areas Fever, malaise, and headache (for chickenpox) Diagnosis: PCR, direct fluorescence antibody test, and clinical signs. --- 3. Human Papillomavirus (HPV) Infections Type: Multiple strains, including HPV types 16 and 18 Common Oral Manifestations: Oral Warts: Benign, non-painful growths typically found on the lips, palate, tongue, and floor of the mouth. Condyloma Acuminatum: Wart-like lesions in the mouth, often associated with genital HPV. Oropharyngeal Cancer: Certain high-risk HPV strains (e.g., HPV-16) are linked to cancers of the oropharynx, including tonsils and base of tongue. Clinical Features: Raised, fleshy, or cauliflower-like growths Rarely associated with pain or discomfort Diagnosis: Biopsy and PCR testing for HPV. --- 4. Coxsackievirus Infections Type: Hand, Foot, and Mouth Disease (HFMD) Common Oral Manifestations: Oral Ulcers: Painful, shallow ulcers typically seen on the soft palate, tonsils, tongue, and buccal mucosa. Vesicular Lesions: Small vesicles that ulcerate to form painful sores. Clinical Features: Red spots or vesicles that turn into ulcers Fever, sore throat, and malaise Rash and lesions on hands and feet Diagnosis: Clinical presentation and PCR. --- 5. Measles (Rubeola) Type: Paramyxovirus Common Oral Manifestations: Koplik Spots: Small, white or bluish-white spots seen on the buccal mucosa opposite the molars before the rash appears. Generalized Oral Ulceration: Following the appearance of Koplik spots, mucosal lesions may develop. Clinical Features: High fever, cough, and rash (starts on the face and spreads) Conjunctivitis Koplik spots as early indicators Diagnosis: Clinical signs and serology for measles antibodies. --- 6. HIV/AIDS Type: Human Immunodeficiency Virus Common Oral Manifestations: Oral Candidiasis: Fungal overgrowth in the mouth due to immunosuppression. Kaposi's Sarcoma: A form of cancer that appears as purple or brown lesions in the mouth, especially in the palate or gingiva. Oral Hairy Leukoplakia: White, hairy lesions on the lateral borders of the tongue, often associated with Epstein-Barr virus. Herpes Simplex and Zoster: Recurrent infections in the oral cavity. Clinical Features: Candidiasis: White plaques that can be scraped off Kaposi’s Sarcoma: Purple, macular lesions Hairy Leukoplakia: White, corrugated patches on the tongue Recurrent infections and oral ulcers Diagnosis: HIV testing, biopsy for Kaposi's sarcoma, and culture for candidiasis. --- 7. Influenza Virus Type: Influenza A and B Common Oral Manifestations: Pharyngitis: Sore throat and erythema of the oropharyngeal mucosa. Dry Mouth: Often secondary to fever and dehydration. Mucosal Erosions: Rare, but may occur in severe cases. Clinical Features: Fever, cough, sore throat, muscle aches, and headache Red or swollen tonsils and oral mucosa Diagnosis: Rapid influenza tests and PCR. --- 8. Epstein-Barr Virus (EBV) Type: Epstein-Barr virus Common Oral Manifestations: Oral Hairy Leukoplakia: White, asymptomatic, corrugated patches on the lateral borders of the tongue. Pharyngitis: Sore throat with swelling of tonsils. Oral Ulcers: Occasionally seen in association with infectious mononucleosis. Clinical Features: Fever, sore throat, and swollen lymph nodes (mononucleosis) Fatigue and malaise Diagnosis: EBV serology and PCR. --- 9. Rabies Virus Type: Rabies virus Common Oral Manifestations: Hydrophobia: Difficulty swallowing and fear of water. Increased Salivation: Resulting from dysfunction in the throat and jaw muscles. Clinical Features: Progressive neurological symptoms Paroxysms of pain or spasms in the throat and mouth Diagnosis: Clinical signs, rabies testing (saliva, CSF, or tissue biopsy). --- 10. Human Immunodeficiency Virus (HIV) Common Oral Manifestations: Oral Candidiasis: White, creamy lesions in the mouth, especially in immunocompromised individuals. Kaposi’s Sarcoma: Purple or red lesions on the palate and gingiva. Herpes Simplex: Recurrent oral lesions. Oral Hairy Leukoplakia: A condition linked with Epstein-Barr virus, presenting as white patches on the lateral borders of the tongue. --- Conclusion Oral manifestations of viral infections are varied and can provide valuable clues for diagnosing systemic viral diseases. Clinicians must consider the specific features and patterns of lesions in combination with other clinical signs for an accurate diagnosis. Some infections may also have long-term oral health implications, requiring management and prevention strategies.Conjuction test part 2Conjuction test Pre-Test (ELA) - ConjunctionsPRACTICE TEST Q2 CONJUNCTIONSMake a 25 question test about sentence type identification with simple, compound, complex, compound-complex, subordinate clause, coordinating conjunctions, subordinating conjunctions, clause