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nbme21/Block 3/Question#31 (50.7 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 itnkh eht ecnpotc eyhe’rt tsgenti is eth acnrdesei GTB velles ni ycpn,grane nad tno utsj mdrhsrthyeyipio ni .gnelear

ehnW icnengres orf ,p/sohypdomitheyyrhri TSH velles rea YWSALA teprlirenfealy cdcehke bueseca ythe aer roem ntieesivs to mueitn rscfeefnedi in 3/T.4T netOf tmeis HST eesvll acn ntaetrmdsoe a ghncae vene enwh T4T/3 lleesv are in het auncilisblc en.arg ehT ylno onctexiep to tihs ldouw be in ynrnegapc (dan I guess bayme ivler irfaelu? I todub heyt wudlo aks htsi u)hht.go iHgh oengerts llsvee rnpesvte the rievl from rgbniaek onwd TG,B ligedna to aicresdne BTG lelsve ni eht smr.ue ishT bdins to fere ,4T ngieacsdre the unotma fo aiveablal rfee T4. As a mtyecpnsoroa mhec,asinm HTS esvlel ear nynsatelrit ecesardni nda het ERTA of 4T otnpiurcdo is esancedri to linsprhee enailebs eefr 4T v.elels vweroeH hte TALOT utmnao fo T4 is ieedncras.

hTe oiseutnq si iagksn owh to nifcmor shyiiyrmtodhrep in a angrpent wmnao g&;--t yuo ndee ot ckech EERF T4 velesl sacuee(b they lsohdu eb mlnora due ot pneaomoytrsc eo.s)snepr Yuo nncato ckhec THS sl(auylu tvledeea in recyngpna ot eptmaeoscn fro dneraceis GT),B and yuo notnac ehkcc otlta 4T lleves ilw(l eb eacsndi.re) uoY ogt teh easnwr thrig hireet ywa tub I tkinh sthi si a ftidenerf nagienrso owhtr noesgridi,cn eeaubcs ehty cna ska tish optnecc in teohr xotncets of ehgseo,prierynmts- nad if yhet teisdl SHT“” sa na resnwa echoci atth dowlu eb neoicrtcr.

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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hhmoyrHpoeyirt/isdpy si gnsdaedio iwth THS /w erlefx ot 4T tsi(h just leslt eth lba fi THS is manrol ’tndo kcceh 4T tub fi HST is ml,aoanbr ckech T4 t.o)o TSH na’tws an poniot so T4 is the tbse anwe.sr

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. +