<prompt> Please answer with one of the option in the bracket. Write reasoning in between . Write answer in between .Q:A 64-year-old man who has not seen a physician in over 20 years presents to your office complaining of recently worsening fatigue and weakness, a decreased appetite, distended abdomen, and easy bruising. His family history is notable for a mother with Hashimotos thyroiditis, a sister with lupus and a brother with type II diabetes. On further questioning, the patient discloses a history of prior alcoholism as well as intravenous drug use, though he currently only smokes a pack per day of cigarettes. On physical exam, you note the following findings see Figures A-C as well as several ecchymoses and telangiectasias. As the patient has not seen a physician in many years, you obtain the following laboratory studies:Leukocyte count: 4,100mm3Hemoglobin: 9.6 gdLPlatelet count: 87,000mm3Prothrombin time PT: 21.0 secondsInternational Normalized Ratio INR: 1.8Serum:Creatinine: 1.7 mgdLTotal bilirubin: 3.2 mgdLAspartate aminotransferase AST: 225 ULAlanine aminotransferase ALT: 103 ULAlkaline phosphatase: 162 ULAlbumin: 2.6 gdLSerum thyroxine T4: 3.1 μgdLThyroid-stimulating hormone TSH: 3.4 μUmLWhat is the cause of this patients low serum thyroxine?? A: Autoimmune thyroiditis, B: Urinary loss of thyroxine-binding globulin due to nephrotic syndrome, C: Acute hepatitis causing an elevation in thyroxine-binding globulin, D: Transient central hypothyroidism sick euthyroid syndrome, E: Decreased liver synthetic function,  <response>: This is a clinical vignette describing a 64-year-old man with a history of alcoholism, IV drug use, and smoking presenting with fatigue, weakness, decreased appetite, abdominal distention, easy bruising, low blood counts, coagulopathy, and abnormal liver function tests. Key findings on exam include ecchymoses, telangiectasias, and low serum T4 with normal TSH. The question asks about the cause of his low T4. Choice A can be eliminated since there is no evidence of autoimmune thyroiditis. Choice B can also be eliminated since there are no signs of nephrotic syndrome. Choice C is incorrect because acute hepatitis would cause an increase, not decrease, in thyroxine binding globulin. Choice D does not fit with the normal TSH. Choice E is the correct answer. The patient has evidence of advanced liver disease based on the physical exam findings, low albumin, elevated PTINR and bilirubin, which can all impair liver synthesis of proteins like thyroxine binding globulin. This would lead to decreased total T4 levels.E: Decreased liver synthetic function 