Morning Rounds \u00b7 Clinical Numericals \u00b7 Round 06<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&display=swap\" rel=\"stylesheet\">\n<style>\n#ncl06 *,#ncl06 *::before,#ncl06 *::after{box-sizing:border-box;margin:0;padding:0}\n#ncl06{\n --ob:#1A5F7A;--ob-light:#236E8C;--ob-pale:#E6F3F7;--ob-dark:#114455;\n --correct:#2D6B47;--correct-bg:#EAF6EF;--correct-border:#3A9960;\n --wrong:#B83232;--wrong-bg:#FDF0F0;--wrong-border:#E53935;\n --ink:#0F2A35;--ink-mid:#2A4D5A;--ink-soft:#5A7D8A;\n --line:#B8D8E3;--cream:#F2F8FA;--warm:#F8FCFD;\n font-family:'Source Serif 4',Georgia,serif;\n font-size:16px;color:var(--ink);background:var(--cream);\n line-height:1.7;padding:0 0 64px;\n}\n#ncl06 .mr-header{background:linear-gradient(135deg,var(--ob-dark) 0%,var(--ob) 60%,var(--ob-light) 100%);color:#E4F4F9;padding:36px 24px 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.mr-band-c{background:var(--correct-bg);color:var(--correct)}\n#ncl06 .mr-band-w{background:var(--wrong-bg);color:var(--wrong)}\n#ncl06 .mr-band-s{background:var(--ob-pale);color:var(--ob)}\n#ncl06 .mr-retry{display:block;margin:18px auto 4px;background:transparent;border:2px solid var(--ob);color:var(--ob);border-radius:8px;padding:9px 28px;font-family:'Playfair Display',serif;font-size:0.92rem;font-weight:700;cursor:pointer;}\n#ncl06 .mr-retry:hover{background:var(--ob);color:#E4F4F9}\n@media(max-width:480px){\n #ncl06 .mr-title{font-size:1.4rem}\n #ncl06 .mr-num{font-size:1.7rem}\n #ncl06 .mr-stem{font-size:0.9rem}\n #ncl06 .mr-opt-text{font-size:0.86rem}\n}\n<\/style>\n\n<div id=\"ncl06\">\n\n <div class=\"mr-header\">\n <div class=\"mr-series-tag\">Numerical Series · Clinical Physiology<\/div>\n <div class=\"mr-eyebrow\">Morning Rounds · Round 06 of 07<\/div>\n <div class=\"mr-title\">Cardiovascular<br><em>Calculations<\/em><\/div>\n <div class=\"mr-subtitle\">Five questions · Mean arterial pressure, SVR, stroke volume, pulse pressure & cardiac index<\/div>\n <div class=\"mr-chips\">\n <span class=\"mr-chip\">5 Questions<\/span>\n <span class=\"mr-chip\">+4 \/ −1 scoring<\/span>\n <span class=\"mr-chip\">Options reshuffled<\/span>\n <\/div>\n <\/div>\n\n <div class=\"mr-sentinel\" id=\"ncl06-sentinel\"><\/div>\n\n <div class=\"mr-progress\" id=\"ncl06-progress\">\n <div class=\"mr-prog-inner\">\n <div class=\"mr-pips\" id=\"ncl06-pips\"><\/div>\n <\/div>\n <\/div>\n\n <div class=\"mr-body\">\n <div id=\"ncl06-cases\"><\/div>\n <div class=\"mr-submit-wrap\">\n <button class=\"mr-btn\" id=\"ncl06-submit\">Submit for Debrief<\/button>\n <\/div>\n <div class=\"mr-score\" id=\"ncl06-score\">\n <div class=\"mr-score-in\">\n <div class=\"mr-score-ey\">Round Complete<\/div>\n <div class=\"mr-ring\" id=\"ncl06-ring\">\n <div class=\"mr-ring-in\">\n <span class=\"mr-ring-pct\" id=\"ncl06-pct\">0%<\/span>\n <span class=\"mr-ring-sub\">net<\/span>\n <\/div>\n <\/div>\n <div class=\"mr-score-title\">Your Debrief<\/div>\n <div class=\"mr-score-net\" id=\"ncl06-net\"><\/div>\n <div class=\"mr-verdict\" id=\"ncl06-verdict\"><\/div>\n <div class=\"mr-bands\">\n <span class=\"mr-band mr-band-c\" id=\"ncl06-ct-c\"><\/span>\n <span class=\"mr-band mr-band-w\" id=\"ncl06-ct-w\"><\/span>\n <span class=\"mr-band mr-band-s\" id=\"ncl06-ct-s\"><\/span>\n <\/div>\n <button class=\"mr-retry\" id=\"ncl06-retry\">↻ New Round<\/button>\n <\/div>\n <\/div>\n <\/div>\n\n<\/div>\n\n<script>\n(function () {\n 'use strict';\n\n var NS = 'ncl06';\n var TOTAL = 5;\n var MAX = 20;\n var LTRS = ['A','B','C','D'];\n\n var QS = [\n\n {\n id: 1,\n tag: 'Mean Arterial Pressure -- Formula and Clinical Use',\n stem: 'A patient has a BP of <strong>90\/60 mmHg<\/strong>. Calculate the <strong>mean arterial pressure (MAP)<\/strong> and state the minimum acceptable MAP for organ perfusion.',\n correct: 'MAP = 70 mmHg; minimum acceptable MAP for adequate organ perfusion is generally 65 mmHg',\n opts: [\n 'MAP = 70 mmHg; minimum acceptable MAP for adequate organ perfusion is generally 65 mmHg',\n 'MAP = 75 mmHg; minimum acceptable MAP is 70 mmHg based on diastolic dominance',\n 'MAP = 70 mmHg; minimum acceptable MAP is 80 mmHg to ensure coronary perfusion in all patients',\n 'MAP = 65 mmHg; calculated as the arithmetic mean of systolic and diastolic pressures'\n ],\n exp: 'MAP = <strong>DBP + (1\/3) x Pulse Pressure<\/strong>, or equivalently: <strong>(SBP + 2 x DBP) \/ 3<\/strong>.<span class=\"calc\">Pulse pressure = 90 - 60 = 30 mmHg<br>MAP = 60 + (1\/3 x 30) = 60 + 10 = <strong>70 mmHg<\/strong><br><br>Cross-check: (90 + 2x60) \/ 3 = 210 \/ 3 = 70 mmHg<\/span>The 1\/3 weighting reflects the fact that diastole occupies approximately two-thirds of the cardiac cycle at normal heart rates. MAP is the true driving pressure for organ perfusion -- not systolic, not diastolic alone.<br><br>Clinical target: <strong>MAP greater than or equal to 65 mmHg<\/strong> is the standard sepsis resuscitation target (Surviving Sepsis Campaign). Higher targets (70-80) may be needed in patients with chronic hypertension or known coronary artery disease.<br><br>Trap D uses the arithmetic mean (90+60)\/2 = 75 -- wrong formula. Trap B gets the calculation right but states 70 mmHg as the minimum -- the standard threshold is 65. Trap C overstates the minimum to 80 mmHg.'\n },\n\n {\n id: 2,\n tag: 'Systemic Vascular Resistance -- Calculation and Shock Classification',\n stem: 'A septic patient has: <strong>MAP 55 mmHg, CVP 4 mmHg, cardiac output 8 L\/min<\/strong>. Calculate the <strong>SVR<\/strong> and classify the haemodynamic pattern.',\n correct: '637 dynes\/sec\/cm5; low SVR with high CO -- distributive (septic) shock pattern',\n opts: [\n '637 dynes\/sec\/cm5; low SVR with high CO -- distributive (septic) shock pattern',\n '637 dynes\/sec\/cm5; high SVR with high CO -- hypertensive crisis pattern requiring vasodilators',\n '51 dynes\/sec\/cm5; critically low SVR indicating vasoplegic shock requiring phenylephrine',\n '6375 dynes\/sec\/cm5; markedly elevated SVR indicating cardiogenic shock with compensatory vasoconstriction'\n ],\n exp: 'SVR formula: <strong>SVR = [(MAP - CVP) \/ CO] x 80<\/strong>.<span class=\"calc\">SVR = [(55 - 4) \/ 8] x 80<br>= [51 \/ 8] x 80<br>= 6.375 x 80<br>= <strong>510 dynes\/sec\/cm5<\/strong><\/span>Normal SVR: <strong>800-1200 dynes\/sec\/cm5<\/strong>. SVR of 510 is low. CO of 8 L\/min is high (normal 4-8 L\/min, upper limit). This pattern -- <strong>low SVR + high CO<\/strong> -- is the haemodynamic fingerprint of <strong>distributive shock<\/strong> (sepsis, anaphylaxis, neurogenic).<br><br>The x80 factor converts mmHg.min\/L (Wood units) to dynes\/sec\/cm5 (CGS units). Both are valid; x80 is the conversion.<br><br>Shock patterns:<br>- Cardiogenic: low CO, high SVR<br>- Distributive\/Septic: high CO, low SVR<br>- Hypovolaemic: low CO, high SVR<br>- Obstructive (PE\/tamponade): low CO, high SVR<br><br>Trap C drops the x80 factor giving 51. Trap D uses the formula correctly but misidentifies the pattern as cardiogenic.'\n },\n\n {\n id: 3,\n tag: 'Stroke Volume and Ejection Fraction',\n stem: 'An echocardiogram shows: <strong>end-diastolic volume (EDV) 140 mL, end-systolic volume (ESV) 60 mL<\/strong>. Heart rate is <strong>75 bpm<\/strong>. Calculate <strong>stroke volume, ejection fraction, and cardiac output<\/strong>.',\n correct: 'SV = 80 mL; EF = 57%; CO = 6 L\/min',\n opts: [\n 'SV = 80 mL; EF = 57%; CO = 6 L\/min',\n 'SV = 80 mL; EF = 43%; CO = 6 L\/min',\n 'SV = 200 mL; EF = 57%; CO = 15 L\/min',\n 'SV = 80 mL; EF = 57%; CO = 4.8 L\/min'\n ],\n exp: '<span class=\"calc\">Stroke Volume = EDV - ESV = 140 - 60 = <strong>80 mL<\/strong><br><br>Ejection Fraction = SV \/ EDV x 100 = 80 \/ 140 x 100 = <strong>57%<\/strong><br><br>Cardiac Output = SV x HR = 80 mL x 75 bpm = 6000 mL\/min = <strong>6 L\/min<\/strong><\/span>Normal values:<br>• EF: <strong>55-70%<\/strong> (normal); 40-54% (mildly reduced); less than 40% (HFrEF)<br>• CO: 4-8 L\/min<br>• SV: 60-100 mL<br><br>EF = 57% is normal. This is a normal heart. The EF formula divides by <strong>EDV<\/strong> (the maximum volume), not ESV. Trap B divides SV by EDV+ESV (200) giving 40% -- wrong denominator. Trap C adds EDV+ESV instead of subtracting. Trap D calculates CO correctly using SV x HR but arrives at 4.8 -- a multiplication error (80 x 75 = 6000, not 4800).<br><br>Clinical anchor: EF is the single most important number on an echo report. It determines HF classification (HFrEF vs HFpEF) and drives treatment decisions including CRT, AICD, and transplant listing.'\n },\n\n {\n id: 4,\n tag: 'Pulse Pressure -- Aortic Regurgitation and High-Output States',\n stem: 'A patient has BP <strong>160\/40 mmHg<\/strong>. Pulse pressure is <strong>120 mmHg<\/strong>. Which conditions produce a <strong>widened pulse pressure<\/strong> and what is the haemodynamic mechanism in each?',\n correct: 'Aortic regurgitation, thyrotoxicosis, severe anaemia, arteriovenous fistula -- all increase stroke volume or reduce diastolic runoff, raising SBP and\/or lowering DBP',\n opts: [\n 'Aortic regurgitation, thyrotoxicosis, severe anaemia, arteriovenous fistula -- all increase stroke volume or reduce diastolic runoff, raising SBP and\/or lowering DBP',\n 'Aortic stenosis, hypertrophic cardiomyopathy, cardiac tamponade -- outflow obstruction increases afterload and widens pulse pressure',\n 'Aortic regurgitation, cardiac tamponade, tension pneumothorax -- all reduce venous return and cause reflexive widening of pulse pressure',\n 'Severe hypertension alone -- sustained elevation of systolic pressure is sufficient to widen pulse pressure without diastolic involvement'\n ],\n exp: 'Pulse Pressure = <strong>SBP - DBP<\/strong>. Normal = 30-50 mmHg. Widened pulse pressure = greater than 60 mmHg.<span class=\"calc\">This patient: PP = 160 - 40 = <strong>120 mmHg<\/strong> -- markedly widened<\/span>Mechanism of widening -- two pathways:<br><br><strong>1. Increased stroke volume (raises SBP):<\/strong><br>• Aortic regurgitation: regurgitant volume added to normal SV<br>• Thyrotoxicosis: high-output state, increased SV and HR<br>• Severe anaemia: compensatory high-output state<br>• Arteriovenous fistula: shunted blood returns rapidly, increasing effective venous return and SV<br>• Bradycardia: more filling time per beat, larger SV<br><br><strong>2. Reduced diastolic pressure (lowers DBP):<\/strong><br>• Aortic regurgitation: blood runs back into LV during diastole, reducing aortic DBP<br>• Arteriovenous fistula: rapid runoff through fistula drops DBP<br><br>Trap B lists conditions that cause <em>narrow<\/em> pulse pressure (tamponade reduces SV; AS reduces SBP). Tamponade classically causes <strong>pulsus paradoxus<\/strong> and a narrow, not wide, pulse pressure. Trap C mixes widening and narrowing causes.'\n },\n\n {\n id: 5,\n tag: 'Cardiac Index -- Indexing for Body Surface Area',\n stem: 'A patient has a <strong>cardiac output of 3.6 L\/min<\/strong> and a <strong>body surface area of 1.8 m2<\/strong>. What is the <strong>cardiac index<\/strong>, and how should this value be interpreted?',\n correct: '2.0 L\/min\/m2; reduced cardiac index indicating low cardiac output state -- cardiogenic shock threshold is below 2.2 L\/min\/m2',\n opts: [\n '2.0 L\/min\/m2; reduced cardiac index indicating low cardiac output state -- cardiogenic shock threshold is below 2.2 L\/min\/m2',\n '2.0 L\/min\/m2; normal cardiac index since it exceeds the lower limit of 1.8 L\/min\/m2',\n '6.5 L\/min\/m2; calculated as cardiac output multiplied by body surface area',\n '2.0 L\/min\/m2; reduced index indicating distributive shock since CO is proportionally low for body size'\n ],\n exp: 'Cardiac Index = <strong>Cardiac Output \/ Body Surface Area<\/strong>.<span class=\"calc\">CI = 3.6 L\/min \/ 1.8 m2 = <strong>2.0 L\/min\/m2<\/strong><\/span>Normal CI: <strong>2.5-4.0 L\/min\/m2<\/strong>. CI of 2.0 is below normal.<br><br>CI thresholds in cardiogenic shock:<br>• CI less than 2.2 L\/min\/m2: <strong>cardiogenic shock threshold<\/strong> (Forrester classification)<br>• CI less than 1.8 L\/min\/m2: severe shock, very high mortality<br><br>Why index by BSA? A CO of 3.6 L\/min might be adequate for a small person (BSA 1.4 m2, CI = 2.57 -- normal) but clearly inadequate for a large person (BSA 2.2 m2, CI = 1.64 -- severe shock). Raw CO without BSA correction can be misleading.<br><br>Trap B sets the lower limit of normal at 1.8 -- that is the threshold for severe shock, not the lower limit of normal (which is 2.5). Trap C multiplies instead of divides, giving 6.5. Trap D misidentifies the pattern as distributive -- distributive shock produces high CO (and thus high CI), not low CO.'\n }\n\n ];\n\n var answers = {}, answered = 0, shuffled = {}, done = false;\n\n function gid(s) { return document.getElementById(NS + '-' + s); }\n function byId(s) { return document.getElementById(s); }\n\n function shuffleArr(arr) {\n var a = arr.slice(), i, j, t;\n for (i = a.length - 1; i > 0; i--) {\n j = Math.floor(Math.random() * (i + 1));\n t = a[i]; a[i] = a[j]; a[j] = t;\n }\n return a;\n }\n\n function countVal(v) {\n var n = 0, k;\n for (k in answers) { if (answers[k] === v) n++; }\n return n;\n }\n\n function buildPips() {\n var cont = gid('pips'), i, q, wLine, wPip, line, pip;\n cont.innerHTML = '';\n for (i = 0; i < QS.length; i++) {\n q = QS[i];\n if (i > 0) {\n wLine = document.createElement('div');\n wLine.className = 'mr-pip-wrap';\n line = document.createElement('div');\n line.className = 'mr-pip-line';\n line.id = NS + '-pl' + q.id;\n wLine.appendChild(line);\n cont.appendChild(wLine);\n }\n wPip = document.createElement('div');\n wPip.className = 'mr-pip-wrap';\n pip = document.createElement('div');\n pip.className = 'mr-pip';\n pip.id = NS + '-pip' + q.id;\n pip.textContent = String(q.id);\n wPip.appendChild(pip);\n cont.appendChild(wPip);\n }\n }\n\n function build() {\n var cont, i, q, opts, card, top, numDiv, meta, tag, stem,\n rule, optsDiv, expDiv, lbl, txt, j, optEl, ltrSpan, txtSpan;\n\n cont = gid('cases');\n cont.innerHTML = '';\n answers = {}; answered = 0; shuffled = {}; done = false;\n gid('score').style.display = 'none';\n buildPips();\n\n for (i = 0; i < QS.length; i++) {\n q = QS[i];\n opts = shuffleArr(q.opts);\n shuffled[q.id] = opts;\n\n card = document.createElement('div');\n card.className = 'mr-case';\n\n top = document.createElement('div');\n top.className = 'mr-case-top';\n\n numDiv = document.createElement('div');\n numDiv.className = 'mr-num';\n numDiv.textContent = q.id < 10 ? 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{"id":37426,"date":"2026-08-25T22:59:48","date_gmt":"2026-08-25T17:29:48","guid":{"rendered":"https:\/\/atsixty.com\/?p=37426"},"modified":"2026-08-26T06:55:15","modified_gmt":"2026-08-26T01:25:15","slug":"cardiovascular-calculations","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/numericals\/cardiovascular-calculations\/","title":{"rendered":"Cardiovascular Calculations"},"content":{"rendered":"\n\n\n\n\n\n\n\nMorning Rounds \u00b7 Clinical Numericals \u00b7 Round 06<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&display=swap\" rel=\"stylesheet\">\n<style>\n#ncl06 *,#ncl06 *::before,#ncl06 *::after{box-sizing:border-box;margin:0;padding:0}\n#ncl06{\n --ob:#1A5F7A;--ob-light:#236E8C;--ob-pale:#E6F3F7;--ob-dark:#114455;\n --correct:#2D6B47;--correct-bg:#EAF6EF;--correct-border:#3A9960;\n 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#ncl06 .mr-opt-text{font-size:0.86rem}\n}\n<\/style>\n\n<div id=\"ncl06\">\n\n <div class=\"mr-header\">\n <div class=\"mr-series-tag\">Numerical Series · Clinical Physiology<\/div>\n <div class=\"mr-eyebrow\">Morning Rounds · Round 06 of 07<\/div>\n <div class=\"mr-title\">Cardiovascular<br><em>Calculations<\/em><\/div>\n <div class=\"mr-subtitle\">Five questions · Mean arterial pressure, SVR, stroke volume, pulse pressure & cardiac index<\/div>\n <div class=\"mr-chips\">\n <span class=\"mr-chip\">5 Questions<\/span>\n <span class=\"mr-chip\">+4 \/ −1 scoring<\/span>\n <span class=\"mr-chip\">Options reshuffled<\/span>\n <\/div>\n <\/div>\n\n <div class=\"mr-sentinel\" id=\"ncl06-sentinel\"><\/div>\n\n <div class=\"mr-progress\" id=\"ncl06-progress\">\n <div class=\"mr-prog-inner\">\n <div class=\"mr-pips\" id=\"ncl06-pips\"><\/div>\n <\/div>\n <\/div>\n\n <div class=\"mr-body\">\n <div id=\"ncl06-cases\"><\/div>\n <div class=\"mr-submit-wrap\">\n <button class=\"mr-btn\" id=\"ncl06-submit\">Submit for Debrief<\/button>\n <\/div>\n <div class=\"mr-score\" id=\"ncl06-score\">\n <div class=\"mr-score-in\">\n <div class=\"mr-score-ey\">Round Complete<\/div>\n <div class=\"mr-ring\" id=\"ncl06-ring\">\n <div class=\"mr-ring-in\">\n <span class=\"mr-ring-pct\" id=\"ncl06-pct\">0%<\/span>\n <span class=\"mr-ring-sub\">net<\/span>\n <\/div>\n <\/div>\n <div class=\"mr-score-title\">Your Debrief<\/div>\n <div class=\"mr-score-net\" id=\"ncl06-net\"><\/div>\n <div class=\"mr-verdict\" id=\"ncl06-verdict\"><\/div>\n <div class=\"mr-bands\">\n <span class=\"mr-band mr-band-c\" id=\"ncl06-ct-c\"><\/span>\n <span class=\"mr-band mr-band-w\" id=\"ncl06-ct-w\"><\/span>\n <span class=\"mr-band mr-band-s\" id=\"ncl06-ct-s\"><\/span>\n <\/div>\n <button class=\"mr-retry\" id=\"ncl06-retry\">↻ New Round<\/button>\n <\/div>\n <\/div>\n <\/div>\n\n<\/div>\n\n<script>\n(function () {\n 'use strict';\n\n var NS = 'ncl06';\n var TOTAL = 5;\n var MAX = 20;\n var LTRS = ['A','B','C','D'];\n\n var QS = [\n\n {\n id: 1,\n tag: 'Mean Arterial Pressure -- Formula and Clinical Use',\n stem: 'A patient has a BP of <strong>90\/60 mmHg<\/strong>. Calculate the <strong>mean arterial pressure (MAP)<\/strong> and state the minimum acceptable MAP for organ perfusion.',\n correct: 'MAP = 70 mmHg; minimum acceptable MAP for adequate organ perfusion is generally 65 mmHg',\n opts: [\n 'MAP = 70 mmHg; minimum acceptable MAP for adequate organ perfusion is generally 65 mmHg',\n 'MAP = 75 mmHg; minimum acceptable MAP is 70 mmHg based on diastolic dominance',\n 'MAP = 70 mmHg; minimum acceptable MAP is 80 mmHg to ensure coronary perfusion in all patients',\n 'MAP = 65 mmHg; calculated as the arithmetic mean of systolic and diastolic pressures'\n ],\n exp: 'MAP = <strong>DBP + (1\/3) x Pulse Pressure<\/strong>, or equivalently: <strong>(SBP + 2 x DBP) \/ 3<\/strong>.<span class=\"calc\">Pulse pressure = 90 - 60 = 30 mmHg<br>MAP = 60 + (1\/3 x 30) = 60 + 10 = <strong>70 mmHg<\/strong><br><br>Cross-check: (90 + 2x60) \/ 3 = 210 \/ 3 = 70 mmHg<\/span>The 1\/3 weighting reflects the fact that diastole occupies approximately two-thirds of the cardiac cycle at normal heart rates. MAP is the true driving pressure for organ perfusion -- not systolic, not diastolic alone.<br><br>Clinical target: <strong>MAP greater than or equal to 65 mmHg<\/strong> is the standard sepsis resuscitation target (Surviving Sepsis Campaign). Higher targets (70-80) may be needed in patients with chronic hypertension or known coronary artery disease.<br><br>Trap D uses the arithmetic mean (90+60)\/2 = 75 -- wrong formula. Trap B gets the calculation right but states 70 mmHg as the minimum -- the standard threshold is 65. Trap C overstates the minimum to 80 mmHg.'\n },\n\n {\n id: 2,\n tag: 'Systemic Vascular Resistance -- Calculation and Shock Classification',\n stem: 'A septic patient has: <strong>MAP 55 mmHg, CVP 4 mmHg, cardiac output 8 L\/min<\/strong>. Calculate the <strong>SVR<\/strong> and classify the haemodynamic pattern.',\n correct: '637 dynes\/sec\/cm5; low SVR with high CO -- distributive (septic) shock pattern',\n opts: [\n '637 dynes\/sec\/cm5; low SVR with high CO -- distributive (septic) shock pattern',\n '637 dynes\/sec\/cm5; high SVR with high CO -- hypertensive crisis pattern requiring vasodilators',\n '51 dynes\/sec\/cm5; critically low SVR indicating vasoplegic shock requiring phenylephrine',\n '6375 dynes\/sec\/cm5; markedly elevated SVR indicating cardiogenic shock with compensatory vasoconstriction'\n ],\n exp: 'SVR formula: <strong>SVR = [(MAP - CVP) \/ CO] x 80<\/strong>.<span class=\"calc\">SVR = [(55 - 4) \/ 8] x 80<br>= [51 \/ 8] x 80<br>= 6.375 x 80<br>= <strong>510 dynes\/sec\/cm5<\/strong><\/span>Normal SVR: <strong>800-1200 dynes\/sec\/cm5<\/strong>. SVR of 510 is low. CO of 8 L\/min is high (normal 4-8 L\/min, upper limit). This pattern -- <strong>low SVR + high CO<\/strong> -- is the haemodynamic fingerprint of <strong>distributive shock<\/strong> (sepsis, anaphylaxis, neurogenic).<br><br>The x80 factor converts mmHg.min\/L (Wood units) to dynes\/sec\/cm5 (CGS units). Both are valid; x80 is the conversion.<br><br>Shock patterns:<br>- Cardiogenic: low CO, high SVR<br>- Distributive\/Septic: high CO, low SVR<br>- Hypovolaemic: low CO, high SVR<br>- Obstructive (PE\/tamponade): low CO, high SVR<br><br>Trap C drops the x80 factor giving 51. Trap D uses the formula correctly but misidentifies the pattern as cardiogenic.'\n },\n\n {\n id: 3,\n tag: 'Stroke Volume and Ejection Fraction',\n stem: 'An echocardiogram shows: <strong>end-diastolic volume (EDV) 140 mL, end-systolic volume (ESV) 60 mL<\/strong>. Heart rate is <strong>75 bpm<\/strong>. Calculate <strong>stroke volume, ejection fraction, and cardiac output<\/strong>.',\n correct: 'SV = 80 mL; EF = 57%; CO = 6 L\/min',\n opts: [\n 'SV = 80 mL; EF = 57%; CO = 6 L\/min',\n 'SV = 80 mL; EF = 43%; CO = 6 L\/min',\n 'SV = 200 mL; EF = 57%; CO = 15 L\/min',\n 'SV = 80 mL; EF = 57%; CO = 4.8 L\/min'\n ],\n exp: '<span class=\"calc\">Stroke Volume = EDV - ESV = 140 - 60 = <strong>80 mL<\/strong><br><br>Ejection Fraction = SV \/ EDV x 100 = 80 \/ 140 x 100 = <strong>57%<\/strong><br><br>Cardiac Output = SV x HR = 80 mL x 75 bpm = 6000 mL\/min = <strong>6 L\/min<\/strong><\/span>Normal values:<br>• EF: <strong>55-70%<\/strong> (normal); 40-54% (mildly reduced); less than 40% (HFrEF)<br>• CO: 4-8 L\/min<br>• SV: 60-100 mL<br><br>EF = 57% is normal. This is a normal heart. The EF formula divides by <strong>EDV<\/strong> (the maximum volume), not ESV. Trap B divides SV by EDV+ESV (200) giving 40% -- wrong denominator. Trap C adds EDV+ESV instead of subtracting. Trap D calculates CO correctly using SV x HR but arrives at 4.8 -- a multiplication error (80 x 75 = 6000, not 4800).<br><br>Clinical anchor: EF is the single most important number on an echo report. It determines HF classification (HFrEF vs HFpEF) and drives treatment decisions including CRT, AICD, and transplant listing.'\n },\n\n {\n id: 4,\n tag: 'Pulse Pressure -- Aortic Regurgitation and High-Output States',\n stem: 'A patient has BP <strong>160\/40 mmHg<\/strong>. Pulse pressure is <strong>120 mmHg<\/strong>. Which conditions produce a <strong>widened pulse pressure<\/strong> and what is the haemodynamic mechanism in each?',\n correct: 'Aortic regurgitation, thyrotoxicosis, severe anaemia, arteriovenous fistula -- all increase stroke volume or reduce diastolic runoff, raising SBP and\/or lowering DBP',\n opts: [\n 'Aortic regurgitation, thyrotoxicosis, severe anaemia, arteriovenous fistula -- all increase stroke volume or reduce diastolic runoff, raising SBP and\/or lowering DBP',\n 'Aortic stenosis, hypertrophic cardiomyopathy, cardiac tamponade -- outflow obstruction increases afterload and widens pulse pressure',\n 'Aortic regurgitation, cardiac tamponade, tension pneumothorax -- all reduce venous return and cause reflexive widening of pulse pressure',\n 'Severe hypertension alone -- sustained elevation of systolic pressure is sufficient to widen pulse pressure without diastolic involvement'\n ],\n exp: 'Pulse Pressure = <strong>SBP - DBP<\/strong>. Normal = 30-50 mmHg. Widened pulse pressure = greater than 60 mmHg.<span class=\"calc\">This patient: PP = 160 - 40 = <strong>120 mmHg<\/strong> -- markedly widened<\/span>Mechanism of widening -- two pathways:<br><br><strong>1. Increased stroke volume (raises SBP):<\/strong><br>• Aortic regurgitation: regurgitant volume added to normal SV<br>• Thyrotoxicosis: high-output state, increased SV and HR<br>• Severe anaemia: compensatory high-output state<br>• Arteriovenous fistula: shunted blood returns rapidly, increasing effective venous return and SV<br>• Bradycardia: more filling time per beat, larger SV<br><br><strong>2. Reduced diastolic pressure (lowers DBP):<\/strong><br>• Aortic regurgitation: blood runs back into LV during diastole, reducing aortic DBP<br>• Arteriovenous fistula: rapid runoff through fistula drops DBP<br><br>Trap B lists conditions that cause <em>narrow<\/em> pulse pressure (tamponade reduces SV; AS reduces SBP). Tamponade classically causes <strong>pulsus paradoxus<\/strong> and a narrow, not wide, pulse pressure. Trap C mixes widening and narrowing causes.'\n },\n\n {\n id: 5,\n tag: 'Cardiac Index -- Indexing for Body Surface Area',\n stem: 'A patient has a <strong>cardiac output of 3.6 L\/min<\/strong> and a <strong>body surface area of 1.8 m2<\/strong>. What is the <strong>cardiac index<\/strong>, and how should this value be interpreted?',\n correct: '2.0 L\/min\/m2; reduced cardiac index indicating low cardiac output state -- cardiogenic shock threshold is below 2.2 L\/min\/m2',\n opts: [\n '2.0 L\/min\/m2; reduced cardiac index indicating low cardiac output state -- cardiogenic shock threshold is below 2.2 L\/min\/m2',\n '2.0 L\/min\/m2; normal cardiac index since it exceeds the lower limit of 1.8 L\/min\/m2',\n '6.5 L\/min\/m2; calculated as cardiac output multiplied by body surface area',\n '2.0 L\/min\/m2; reduced index indicating distributive shock since CO is proportionally low for body size'\n ],\n exp: 'Cardiac Index = <strong>Cardiac Output \/ Body Surface Area<\/strong>.<span class=\"calc\">CI = 3.6 L\/min \/ 1.8 m2 = <strong>2.0 L\/min\/m2<\/strong><\/span>Normal CI: <strong>2.5-4.0 L\/min\/m2<\/strong>. CI of 2.0 is below normal.<br><br>CI thresholds in cardiogenic shock:<br>• CI less than 2.2 L\/min\/m2: <strong>cardiogenic shock threshold<\/strong> (Forrester classification)<br>• CI less than 1.8 L\/min\/m2: severe shock, very high mortality<br><br>Why index by BSA? A CO of 3.6 L\/min might be adequate for a small person (BSA 1.4 m2, CI = 2.57 -- normal) but clearly inadequate for a large person (BSA 2.2 m2, CI = 1.64 -- severe shock). Raw CO without BSA correction can be misleading.<br><br>Trap B sets the lower limit of normal at 1.8 -- that is the threshold for severe shock, not the lower limit of normal (which is 2.5). Trap C multiplies instead of divides, giving 6.5. Trap D misidentifies the pattern as distributive -- distributive shock produces high CO (and thus high CI), not low CO.'\n }\n\n ];\n\n var answers = {}, answered = 0, shuffled = {}, done = false;\n\n function gid(s) { return document.getElementById(NS + '-' + s); }\n function byId(s) { return document.getElementById(s); }\n\n function shuffleArr(arr) {\n var a = arr.slice(), i, j, t;\n for (i = a.length - 1; i > 0; i--) {\n j = Math.floor(Math.random() * (i + 1));\n t = a[i]; a[i] = a[j]; a[j] = t;\n }\n return a;\n }\n\n function countVal(v) {\n var n = 0, k;\n for (k in answers) { if (answers[k] === v) n++; }\n return n;\n }\n\n function buildPips() {\n var cont = gid('pips'), i, q, wLine, wPip, line, pip;\n cont.innerHTML = '';\n for (i = 0; i < QS.length; i++) {\n q = QS[i];\n if (i > 0) {\n wLine = document.createElement('div');\n wLine.className = 'mr-pip-wrap';\n line = document.createElement('div');\n line.className = 'mr-pip-line';\n line.id = NS + '-pl' + q.id;\n wLine.appendChild(line);\n cont.appendChild(wLine);\n }\n wPip = document.createElement('div');\n wPip.className = 'mr-pip-wrap';\n pip = document.createElement('div');\n pip.className = 'mr-pip';\n pip.id = NS + '-pip' + q.id;\n pip.textContent = String(q.id);\n wPip.appendChild(pip);\n cont.appendChild(wPip);\n }\n }\n\n function build() {\n var cont, i, q, opts, card, top, numDiv, meta, tag, stem,\n rule, optsDiv, expDiv, lbl, txt, j, optEl, ltrSpan, txtSpan;\n\n cont = gid('cases');\n cont.innerHTML = '';\n answers = {}; answered = 0; shuffled = {}; done = false;\n gid('score').style.display = 'none';\n buildPips();\n\n for (i = 0; i < QS.length; i++) {\n q = QS[i];\n opts = shuffleArr(q.opts);\n shuffled[q.id] = opts;\n\n card = document.createElement('div');\n card.className = 'mr-case';\n\n top = document.createElement('div');\n top.className = 'mr-case-top';\n\n numDiv = document.createElement('div');\n numDiv.className = 'mr-num';\n numDiv.textContent = q.id < 10 ? 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