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NBME 21 Answers

nbme21/Block 3/Question#31 (53.2 difficulty score)
A 28-year-old woman at 18 weeks' gestation ...
Free T4🔍,📺
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 +70 
submitted by assoplasty(98),
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I nihtk teh cepcotn ertye’h inttges si teh aeiensdrc TGB esvell ni ynrcgepn,a dna not sujt thoihympeirdsry ni egn.ealr

hWne csegeirnn ofr hhirdyoptmio/yspr,yhe HTS sllvee rae LAYASW yartileneplrfe cceedhk acbeesu tehy rae emor sstnieeiv ot ntmeiu cifneedfers in 4/TT3. ntOfe tseim THS levsle nca oenmedrstta a hgcena neev whne 4T/T3 esevll are ni eht ciacllisnub g.eran eTh nlyo peteocinx to shti wulod eb in npyragenc ad(n I ssgeu abmye rielv feiuar?l I obutd hyte lowdu kas itsh go).uhth hgHi toesrgen levlse verseptn the lierv rfmo nigrkbea nowd BG,T ngdleia to ciesnaedr TBG eslelv in het u.srem ishT nidbs ot efre 4,T eanscidrge the ntouma fo vaaableil feer T.4 As a msrypetnaoco sc,iamnmhe SHT esellv rea rayslientnt ndcaserie dna het ARET fo T4 pcoodnruti is dacrenesi ot pserelnhi slnebeai free 4T e.llesv revHwoe hte OTTAL unamto of T4 is drseceani.

The eoqiutsn si gasnik woh to mniocfr prymtohshiydier in a gneprant amown ;t-g&- oyu eden ot cehkc RFEE T4 lsvele bus(eace hyte dusloh be ornlma due ot aypeocotnmsr r.peessno) Yuo nncota ckhec HST suu(ally eeeatvld in nacprgeyn to cmeesanpto ofr isrdecaen ,T)BG dna uoy nnatco ckhec oltat T4 eeslvl w(ill eb cerea)sni.d uYo got eht wnasre tirgh theeir awy tbu I hktni siht si a fdnteefir iogsanern trwho ricngseodi,n asbeuec hyte nca sak isth eccntop ni hroet nxettocs fo eseysg-peom,tnihrr nda if tyhe telisd “TH”S as na wseanr ohcice taht woldu be rreocnc.it

hungrybox  Extremely thorough answer holy shit thank u so much I hope you ACE Step 1 +9  
arkmoses  great answer assoplasty, I remember goljan talking about this in his endo lecture (dudes a flippin legend holy shit) but it kinda flew over my head! thanks for the break down! +3  
whoissaad  you mean total amount of T4 is "not changed"? 2nd para last sentence. +1  
ratadecalle  @whoissaad, in a normal pregnancy total T4 is increased, but the free T4 will be normal and rest of T4 bound to TBG. If patient is hyperthyroid, total T4 would still be increased but the free T4 would now be increased as well. +2  
maxillarythirdmolar  To take it a step further, Goljan mentions that there are a myriad of things circulating in the body, often in a 1:2 ratio of free:bound, so in states like this you could acutally see disruption of this ratio as the body maintains its level of free hormone but further increases its level of bound hormone. Goljan also mentions that you'd see the opposite effect in the presence of steroids and nephrotic syndromes. So you could see decreased total T4 but normal free T4 because the bound amounts go down. +2  
lovebug  Amazing answer! THX +1  
an_improved_me  Just to add: Pregnancy is not an exception to using TSH in suspected hyperthyroid pregnant patients (not sure in hypothyroid); you would still get a TSH first, and if its unusually low, you would then proceed to measure T4 (free, total), and so on. https://www.uptodate.com/contents/hyperthyroidism-during-pregnancy-clinical-manifestations-diagnosis-and-causes?search=hyperthyroidism%20in%20pregnancy&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H994499 +1  



 -3 
submitted by cantaloupe5(81),
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rhi/yshmprdytHoiyepo is doeindags with STH /w lrxfee to T4 hist( usjt lstle eth lba if HST is lrnmoa ’odtn hckec 4T utb if SHT si ra,amonbl chekc 4T .oo)t HST tn’swa an potnio os 4T is eht tesb swear.n

hello  I don't get why this was downvoted... +2  
maxillarythirdmolar  To take it a step further, Goljan mentions that there are a myriad of things circulating in the body, often in a 1:2 ratio of free:bound, so in states like this you could acutally see disruption of this ratio as the body maintains its level of free hormone but further increases its level of bound hormone. Goljan also mentions that you'd see the opposite effect in the presence of steroids and nephrotic syndromes. So you could see decreased total T4 but normal free T4 because the bound amounts go down. +