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NBME 21 Answers

nbme21/Block 3/Question#31 (50.8 difficulty score)
A 28-year-old woman at 18 weeks' gestation ...
Free T4🔍,📺
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 +66 
submitted by assoplasty(94),
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I inkth teh octecnp r’ehtey tigtnse si eth endcaisre GTB lvelse ni egcprynan, adn ton tusj rdiymhriytsohpe ni nlg.reae

hnWe ngnisreec rof thimrehippdyooshr/yy, TSH evelsl rae WYLAAS eelnrpteirfyal cheedkc csabuee heyt rea rmeo eetsiinvs ot mtneui dinerecfefs in TT4.3/ ntfOe mteis TSH leevsl nac rodtmtaesen a cehgna eenv whne 3TT/4 vselle ear ni the uibisllccan .rgaen Teh noyl neetxiopc ot this owdlu eb in eynrncpga da(n I ssuge byaem ilrve ral?euif I dbout etyh uwold kas tihs .thu)ohg gihH rnsteoeg elvles revtnsep het evlir fmro rgbainek nwod G,BT anidgle to isadecner GTB lleves in teh e.rsum hiTs ibnds to free 4,T resdgeanci eht uomatn fo aivelaalb efre 4.T As a eposanymtroc msn,iahemc HTS evells aer anetsnityrl ieansrdec nad hte ERAT fo T4 icturoopdn is aenedrcis ot ieslhpner belsanie reef 4T eevl.sl voeeHwr eth LTOTA tnoamu fo 4T si sdaenr.iec

The tsnouiqe is isagnk ohw to nmrciof irpyirdsohmehty in a eganrntp ownma ;--t&g oyu need to check FERE 4T lselve eba(csue htey hdslou be alnmro ude ot oresanmcopyt r).nseseop uoY cotann ekhcc THS yusua(ll leedteva in eyapcnnrg to eomtspcnea for icaersnde G,T)B adn uoy ntcnoa hckec atlto T4 lvseel l(ilw be ca)esneidr. oYu ogt het enswar grith ertehi awy utb I nitkh tshi si a dtrenfefi rsnanegio owrht ensg,ionrcdi sbceaeu yhte anc aks ihts epoccnt in hoter esxtcnto fo ne-pi,yhsrreseogmt nda fi yhet esdlti “SHT” sa na awsner ocehic htta dlouw eb nect.rrcio

hungrybox  Extremely thorough answer holy shit thank u so much I hope you ACE Step 1 +8  
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 +  
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 +  



 -4 
submitted by cantaloupe5(77),
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/oyspormrhtiyehHydip si sigdneado whit HTS w/ lrxeef ot 4T htis( juts ltles het alb if STH si amlnro ’dnto echkc 4T tub fi SHT si blmaa,orn check 4T .o)ot HTS ’wstan an poiotn os 4T si het sbte wearsn.

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. +