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NBME 21 Answers

nbme21/Block 3/Question#31 (reveal difficulty score)
A 28-year-old woman at 18 weeks' gestation ...
Free T4 🔍 / 📺 / 🌳
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 +80 
submitted by wired-in(72),
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ienceantnaM odse froulma is Css( × Cl × t)ua ÷ F

rewhe sCs si tde-atstysae egttar lapsma noc.c of ug,dr lC is ercnea,lac uta si sageod irelvtna apm;& F si ailyaoibbv.liati

Neiethr gosead viantler onr yabialloiaibtvi is vng,ie os nnoiirgg eosth m;&ap gigglunp ni teh urenmbs ecl(uafr to ceotnrv tisun ot m:kag//g)yd

(12= gmLu/ × 1 01/m00g u)g × 00(.9 hrgkL// × 0100 /Lm1 L × 24 rh1/ yd)a
= 59.22 gg/kdmay/

iwch...h ntis' yna of the wasnre iccoshe eltsdi. They mstu vhae nddoreu 0.90 /g/krhL to 0.1 k,g//rhL nda iogdn os evsgi acytxle .828 /kdm/yagg eocch(i )C


 +71 
submitted by assoplasty(100),
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I htikn hte cocepnt h’eryet gitents si het edienrasc BGT lelsev ni epnyr,cnag adn ton sutj iresmhtryyhpodi ni r.nealeg

nWeh gnerscnei fro hphtrdohp,syyyioei/mr TSH elevls rae AAWSYL ieerfltrlaenyp ehckdec ceesuba htey rae mreo instseevi ot numiet fnecesridfe ni .TT/43 tOfen miste THS svllee nca aotseenmrdt a hangec neve nehw 43T/T llsvee are in eht salncuibicl ge.anr The nyol txponeiec to shti luowd be ni paenycrng nad( I sgesu eybam eilrv ufrai?el I dtbuo tyhe dwolu aks tsih hg.)htuo Hgih ersonegt lesvle enrpesvt het viler mofr nkbraige dwno TGB, ngdaiel to aidneecrs GTB llseev in the esmu.r hsiT bsnid ot refe T,4 adgrsincee eth mnatou of avalaelbi rfee T4. sA a osymeoprnatc nac,ehismm STH seelvl era rltaeiytnsn dsaeernci nad het TEAR fo T4 tinroupcdo si andesicer to nsiprelhe aenlseib eerf 4T se.lelv orHewve eht ATLTO tnouma fo 4T is sredeni.ca

hTe tnieoqsu si kniags who to inmfocr rhpoiiertsydhmy in a gtenarnp manwo t&g--; oyu need ot kehcc EFER 4T lsevel ebcuesa( ehty dulsho eb mlrnao ude to ysrcmnpeoota .enrpesso) oYu onctna ccehk SHT sylu(lua eeeldatv ni nepygrcna ot octsnemepa fro ieenascrd )GT,B nad you ntocna ckehc ltaot T4 evesll (lwil be ).eeaidnrsc oYu got eth ewnars thgri iether ywa but I tkhin tihs is a rdfnfeeit negrsaoni wthor ,ncsedgriion acsueeb teyh acn ska siht peccnto ni oterh etcnotsx of pytrgoneehsr,es-im and fi heyt tsdiel ”SHT“ as na rswnea ecochi atht oudlw eb eotccrr.ni

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. +3  
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(85),
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sHdrypyhiyeoop/thmri si sdideoang htwi THS /w rxfele ot T4 ith(s tusj setll hte bla fi HST si onalrm ntod’ chekc 4T ubt if THS si n,lmaaobr hceck 4T .t)oo HTS st’anw an nooipt so 4T is the tebs asne.rw

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. +  



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