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NBME 21 Answers

nbme21/Block 2/Question#14 (reveal difficulty score)
A 30-year-old woman comes to the office ...
Abnormal brain development🔍,📺

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submitted by taway(32),
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hsiT tunsiqoe is sdaphre rgaey,tlns utb tsi' yltnseilase gsnkia "thwa odluw hpeanp if itsh owansm' dpiyoryihmhots acebme doeocnnltrul over hte rceuos fo hre nra"?pencgy

cnruryetl rhe SHT si odog ->- eo-erlntwcdolll oHhmPiAs dEHpiCtILoOhTYyTry ghhi STH &-g;-t erh pyhitoyrshmoid usmt ONT be telcleoordn-wll e(du ot poudinrsit fo het SH3TR/HTT//4T irdeocenn )sixa

So, wno atht ew dnusrnedat atth eht queintos is skangi hwt"a luwod anpehp if hre yhtihioorpysmd saw "ndor?elnoulct

esrA:nw eiisnmrtc

I tnhki atth isht sueitnoq is sedraph yctoaiorsu,l but arf be ti rmfo me ot triiciezc eht USLME lngsneici db.o..ra

yotsubato  I think that this question is phrased atrociously, Just like the rest of the NBME +22  
b1ackcoffee  exactly how does maternal hashimoto can cause cretinism? +  
notyasupreme  @b1ackcoffee, it's not maternal hashimoto, basically you just have to disregard the ENTIRE question stem and the last part of the sentence (if the mom's TSH goes up) means that there's hypothyroidism going on, which causes cretinism. +3  
b1ackcoffee  Thanks you @notyasupreme! +  

submitted by direwolf(10),
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sTih hsa ot od hwit tnedgarnsduin wot hn,stgi htat traemlan ophhydsoritymi is kdilne to aesimerrliC/nnut deeemlovpnt fo eht ts,efu and marlno yrpgcnnea oyo.ghslypi nI n,nregpayc cnieserad roeshnom eilmatuts elivr odpctoruin of oisvaur intproes ikle exS oeHmnor igdinnB niGolubl Gh()SyieHo,nxBTr gndniBi lGiuboln )BTG,( .ect More TBG peoducrd = oerm T4/3T is .unobd sLes 3/TT4 sesuca meor TRH ,rseleea mroe TSH eeale,sr and ermo /T43T drnticpoou nitul feer TT43/ leselv ear back to m.anrlo In a omarln gnray,pnce stih pspnahe on nI eoesmon thiw reeipt-insgx iyhootyhirmpds hogt,uh yaradle has edapmiir T/3T4 ,ptduoirnco and ntow' be eabl ot ekep pu ihtw srneiacde md.aedn Threi T3 lliw esi,r btu stih 'town rltsue in dsrneicae T43/T. ai,lcpyTly emown wiht moss'ohaHti iesinrdg to tge tnpgenar lilw nede to iernesac hietr nioehltxyorve osde in itiiactpnnao of isht gpraeyncn en.achg

submitted by thotaak(5),
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myolralN anmaltre T4/3 rae idqeerru rfo ltefa rnbai elvdenemtop eroefb eflat toyridh lndga si dnA erfta tlfea ihrdoyt algdn si erfodm, lefta 34/T hpsle ni iranb demleot.evpn oS enisearc HTS eamns decreaeds lremntaa 4T/3 nda suth ehav nba aibrn etl.pdomvnee dnA esy /T43 oesrssc

thotaak  According to Robbins pathology +1  

submitted by medschoollovin(14),
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muoinumAet dtrsyhiiiot (aka )thoHsiamo + ttenn&g-prga-; knTih obtau itiiobpslsy of atlfe rdhiohpyomiyst edu to tdboinay ditmedea tlenaamr rimtos.hpyihody sedLa to Cnreisim.t gFinndsi ni nfnita aer teh 6P' t(oP eyllb, l,Pae yPuff cf,ae gdrnriotuP uibslu,cim rbtrntPoeau o,gunte nda Poro rnBai dmtee.neolvp

neonem  I don't understand the last part of this question stem though... if the mother's TSH *increases* during pregnancy? Wouldn't this further increase her (and/or the fetus's) production of T4 and thus counteract the hypothyroidism? +  
poojaym  @neonem no. Autoimmune hypothyroidism is a destruction of the thyroid gland, and a decrease in production of T3/T4. An increase in TSH means that there is not enough T3/T4 to inhibit TRH, and so TSH is being released to stimulate the thyroid gland. +39  
arezpr  TSH, T3, T4 and thyroglobulin cannot cross the placental barrier. +  
chamaleo  @arezpr although those hormones can't cross, the autoantibodies from Hashimoto's can +1  
yotsubato  The baby has its own TSH though +  
sbryant6  TSH comes from the pituitary, and act on the thyroid. Autoantibodies attack the thyroid, so TSH doesn't work. +  
kimcharito  no goiter then? +  
lola915  I think there is no goiter because the baby's thyroid gland has not fully developed and these immunogloblulins from the mother could attack the thyroid gland leading to issues with it's development. +  

submitted by apurva(82),
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ehT alre hntig is TSH, 3,T T4 and gnbotoylihurl ncaton ssrco tpe.cnala TR,H Ione,di TIS acn fc.Iross erhmot sah high HTS esgo(rcidnni apirrmy hoor)idmhstypiy —g&;t oroP irnab I vdepelmeotfn eotrmh has TIS oHm)aisoht( ;g—t& csros hte lpaltance rrreaib cI—erasen in tdiryoh lnadg Ma(y trnpees thwi rrodsit at t.irhb

demihesmisome  Ahhhhh Thank you. This was what I was trying to understand. +1  
apurva  please note that free t4 can cross the placenta +3  

submitted by b1ackcoffee(62),
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tlaexyc woh eods eltmnaar ihoomsath cna secau cm?niserti

lola915  Hashimito is caused by antibodies against thyroid peroxidase and thyroglobulin. Those antibodies can cross the placenta and affect babies thyroid gland causing congenital hypothyroidism. +1  

submitted by thisisfine (27),
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I ihtkn shti tseg at a peotncc edelart to dytrhio eelvsl adn negtpgcoyaernrn/se.

gtneosEr eancseisr teh elvel fo inoxeyi-idnbngrht libo,lung whhci mtrlpaeoriy cessaeerd eref T4 dan 3,T dna eanicsrse HST nitlu the dianotdali GTB smboeec ued,tatras dan ornalm velles era etosr.rde

icSen ihst ntptaei sah niomtemauu triyi,tohdis dan eriursqe niryhotxe, hwen hre reef 4T cas,edsere dna rhe TSH gose pu, hes notw eakm txrea 4T. oS neussl ehs icaesnres erh txirneyho e,dos she iwll be tdrphyooiyh ;tg&-- cisimenrt in the fesut

submitted by neolidone(1),

This is a very tricky question in terms of phrasing it. They make us think about what effect high TSH does on a fetus while it really meant what can happen to the baby in an antibody-mediated hypothyroidism mother. So sneaky so so sneaky...

submitted by seagull(1688),
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This reatcli islaf to etonmni roop riabn tompeelvnde in .hiRPryimdotsYEH eTh rtuhoa smtu evah naetm HhYPostyOii.rmd

hsiT uqistoen suteps me ot no ed.n

aesalmon  I agree, the article you linked states "signs of fetal hyperthyroidism such as tachycardia, intrauterine growth retardation, cardiac failure, and the development of fetal goitre" I chose answer E during the exam - "Thyroid gland enlargement" Still trying to understand how they linked cretinism to a case where the mother's hypothyroidism was well controlled, and then asked for the sequelae if her TSH increased. Maybe increased TSH is supposed to indicate worsening hypothyroid - low T3/T4 needing to be stimulated by TSH? +  

submitted by tissue creep(117),
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My uohhttg sseorcp wsa if the mtreho sah acsdnriee TH,S 'hdse eb sunig orem odeini ot durcpoe 4./T3 egMnnia essl wuldo be bael ot teg ot eth ybba fro anibr eoetlevpnm.d

submitted by hayayah(1115),
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tCisnmier o(eilanntgc d)yphsioyrmtiho si het stom mncoom sauce of ebetarlta nmltae si.badlyiit sCesau proo nrbia le.emeoptnvd

submitted by varunmehru(4),
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The romthe sah otanmiuemu hryiiitodst nda aemtrtnet si ngiev orf rsoyohdphiymit .olny hwy soed it tmrtae fi het setmhro' SHT is ighh ro ?wol iadAtouioesbtn uldwo ltils be epenrts and yhet dowlu salway esacu rnietsicm pvrsicieteer fo mrohet enoshmor .eelvl Itns' t?i