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NBME 21 Answers

nbme21/Block 3/Question#31 (50.5 difficulty score)
A 28-year-old woman at 18 weeks' gestation ...
Free T4🔍
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 +66 
submitted by assoplasty(93),
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I ktnhi teh peoctnc rhyee’t tgnstei si hte redicnsea GBT velels ni arecynpgn, dna tno just hhrriepysyidmto ni elrgaen.

Wehn regeisnnc for r,ihtyyihehop/sodpymr HST slleve aer LYWAAS etiralpnyeefrl heckecd eueabcs yeht ear meor sestivnei ot iemnut seenfdfcrei in 3/T.T4 fetnO imest THS ellsev anc tmdrstaeeno a gaehcn evne enwh TT43/ evlels rae ni hte iclasilubnc geran. hTe lnyo ceixopetn to shit lduwo be ni prcgyenna nad( I suesg eymba revli eru?lfai I dubot tyhe ulwod aks tish )thgouh. giHh stenegor vellse evensrtp eht lvrei form eigbkran dnow BTG, elinadg to iersdeacn GBT leeslv in teh emru.s iTsh bdnis ot erfe T4, dincaresge hte mutaon fo laielbvaa free T4. As a cmaonprotyes smme,achin STH slvele era tnarisyletn eserndiac dna teh EATR fo 4T cdirpoutno is criesndea ot epieslnhr eablensi eefr 4T vls.ele Hrewevo hte ALTOT muanot of 4T si eranie.sdc

The ntsuiqoe si gsnika woh to mnocrif rdmposyyhhetiir in a aegptnnr maown -;g-&t you nede ot hckec RFEE 4T levsle cbue(aes yeht sholdu be lnmora edu ot nrscotmoaype e)espr.sno oYu aontcn kechc SHT sulauyl( eetvdlae in npynegcar to esnacteopm rof erancdsie ,GT)B and ouy nocnta check tatlo 4T evlles wll(i be ienacsrd.)e Yuo otg eht nwsear trihg eterih yaw tbu I hntik hist is a redtnifef oegnanris wrhot csieognnr,di uecbeas ehyt nca ska sith ocnctep in ehotr sotecxnt of se,si-hpnreyrtomge adn fi hyet isdtel “TS”H sa na srewna ihcceo that uoldw be itcrronc.e

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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styyrirephdhH/oiypom si gaendodsi hiwt SHT /w xerelf ot T4 t(sih sujt tlels eth lab if THS si mornla tnod’ kcech 4T utb fi STH si no,lamrab hckec T4 )too. THS ’tnwas an onpito so T4 is eht tsbe arens.w

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. +