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NBME 21 Answers

nbme21/Block 3/Question#31 (45.3 difficulty score)
A 28-year-old woman at 18 weeks' gestation ...
Free T4🔍
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 +61 
submitted by assoplasty(89),
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I tkinh het ptoncce ethry’e estintg is eth dnserciae TBG lesevl in ,aygnrnpec adn nto tusj imyrpdihsretyho ni grn.alee

eWnh ecersnngi fro yy,hrtpphm/roiseoydih HST llvese era SWAAYL efapyertrniell cedchek ecsueba yhet era moer insvsetei ot umenti niredfsfcee in ./TT34 nefOt ietms SHT sleevl can onemrdtseat a heganc eenv nehw T34/T leesvl rae ni the ucciabllisn eanrg. ehT ynol nexticope ot thsi oudwl eb in aeygrpncn ad(n I seugs ebyma ivelr irl?aufe I outdb heyt wludo sak itsh hg.htou) ighH tesoengr levesl rensetpv het irevl frmo kegrniba wodn ,TBG ngiadel ot rciseadne GTB svelle ni hte .resmu ishT ndbis to refe 4,T cngseirade eht umntoa fo beiavalla rfee 4.T As a oascnpryetmo ,smhmeinac TSH lvseel aer iyrennttasl diescaner nda teh ETRA fo 4T urictonpdo si deiecsran to spiehelnr aneisleb free T4 eesllv. rvwHeeo the OTATL otnaum fo 4T is irecesna.d

The iqnsueto is inagsk owh to fmrncoi ermsdhyytpiriho in a rgtnnape nmwao g-t;&- uoy eend ot check ERFE T4 llesev a(ceuseb eyth huodsl be anorml ude to cmotsanpryoe p.ereon)ss ouY atnnco check STH s(lluayu atdlevee in ynnrecgpa ot ectosnpmea rof sdaecerni BT,)G dna ouy conatn hecck oltta T4 llesve ill(w be seae.nrc)di oYu tog het rewans trihg tiehre way tbu I iktnh sthi is a inedetffr gnnisreoa hwotr c,srnodieing cbsauee ythe acn sak isht pentocc ni etorh ctsxneot fo -hne,mtegsyrpoeris adn fi teyh selidt THS“” sa an rwsane coheci that duwol eb rteccor.in

hungrybox  Extremely thorough answer holy shit thank u so much I hope you ACE Step 1 +5  
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! +2  
whoissaad  you mean total amount of T4 is "not changed"? 2nd para last sentence. +  
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. +1  
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. +1  
lovebug  Amazing answer! THX +  



 -4 
submitted by cantaloupe5(69),
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homrihspd/yHryipoyet si adoisendg hwti THS /w exlfer ot T4 ihs(t ustj tesll hte lab fi TSH si ormanl t’don khcec T4 but fi TSH is a,larnbmo chkce T4 oot.) HST wnts’a na ipnoot os 4T si eht best ens.wra

hello  I don't get why this was downvoted... +1  
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. +