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Welcome to misterdoctor69’s page.
Contributor score: 45

Comments ...

 +1  (nbme20#42)

In case anyone was wondering, meningiomas are more common in women (perhaps due to an estrogenic effect, but this is still hotly debated).

Also, GBM's would show up as butterfly-shaped and intraparenchymal. They have a 60% higher incidence in males than females. Historical aside - Ted Kennedy died from a GBM

 +3  (nbme20#30)

To add on, a trauma to the skull => middle meningeal artery laceration => epidural hematoma. Epidural hematomas are known to cause transtentorial herniations and CN III palsy, which is what led to the patient's right pupil being dilated and poorly reactive (ipsilateral to the side of trauma).

 +1  (nbme20#30)

FOOSH (Fall on outstretched hand):

Most common fracture = scaphoid Most common dislocation = lunate

 +8  (nbme24#35)

Damn everyone out here looking at the eyes when my dumbass was thinking the girl was missing a nasal bridge or something lol fml

peridot  That is straight up what I wrote: "low nasal bridge???" I was like is this part of some congenital defect +

 +1  (nbme24#7)

Mixed up cytoscopy with culposcopy so I put HPV. Insert upsidedownsmileyface.jpg

j44n  if it makes you feel better I miss ID'd the PCT not once but twice on this exam +1
tobias  Same!I was so confused by why I got the answers wrong. +

 +3  (nbme24#1)

I think something not mentioned yet is the fact that odds ratio can be used to estimate relative risk in RARE diseases as per the Rare Disease Assumption (where disease prevalence is <10%). Although the cancer in this question is described as "common," (common relative to other cancers), the cancer is still probably rare overall.

 +0  (nbme24#47)

Anyone else got thrown off by their use of HNPCC rather than Lynch syndrome?

 +1  (nbme24#35)

How come melanocytes:basal keratinocytes don't also have a desmosomal connection (in addition to their E-cadherin link)?

vivijujubebe  melanocyte is not part of the epidermal structure. they're at the epidermal-dermal junction and they produce melanin which is transported to the epidermal +1

Subcomments ...

submitted by step1soon(48),
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Lkoo ta eerhw hte spcus are gnpniiot → rpduswa refhetroe ir.atco if uspsc wree dnorwdwa → enht aimltr elvva lwduo eb the tgirh nwares

misterdoctor69  mitral valve would only have 2 cusps even if it were replaced though right?... +  
bbr  After staring at this for awhile, I wanted to elaborate on this to make it even clearer. The 3 areas that meet at a point would be the 3 cusps. These 3 flaps are going to get blown open. Means flow is from down to up. +3  

submitted by nicnac20(18),
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ieMdx uonsve gyonxe nientso is the umoant of gnoyex nobud ot nhibooelmg as it rusnetr ot the ghrti seid fo the eahrt faret anvlgtrei to eht .tssuesi

esaecDder oxygne dyevreil ot teh isusets ude ot eeceddasr radccai ttuopu adesl to eht teisssu cgxtnraite rome ynxego ofmr hte pignssa CRBs athn yhet nromllay ,uwldo hicwh aerdecses the vloalre emdix suevon yxogne .tienons

pparalpha  A helpful equation is CO=rate of O2 consumption/(arterial O2 content-venous O2 content): Fick principle If CO is decreased, then the difference between arterial O2 content and venous O2 content is increased +15  
misterdoctor69  To clarify a little bit, the tissues wouldn't necessarily extract MORE oxygen from the passing RBCs than they normally would. They would extract the same amount as they normally would to carry out their own functions. However, because the starting amount of O2 delivered to tissues is lower, you'd end up with less O2 bound to hemoglobin returning to the right heart. +5  

submitted by hayayah(1079),
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LLHEP :enyromsd vaElldy itHsseeome eirvL nywoeeL zsm Pesa.tellt

A steitanmifnao fo eeesrv slcpp.emiarae Bldoo measr soshw tycotscsi.she nCa dela ot CID adn ephtcai uaosmbaucherma plstas Ž utuprre Ž evrsee noyhnsipote.

mambaforstep  FA 2019 pg 629 +2  
qball  One thing I find odd with this question is HELLP is a manifestation of severe preeclampsia but she has had an otherwise unremarkable pregnancy. Shouldn't she have hypertension/edema in regards to her pregnancy beforehand? +  
demihesmisome  Pre-eclampsia, if not severe, can be entirely asymptomatic. +1  
misterdoctor69  Her blood pressure is 164/102, which qualifies her as having preeclampsia. +  

submitted by b1ackcoffee(46),

wrist extensors (tennis - backhand)--> lateral epicondyl wrist flexors (golf - think near shot - don't know what it's called) - medial epicondyl

b1ackcoffee  fucked formatting. +  
misterdoctor69  I think the word you're look for is "putt." But yup this is right. +  

submitted by hello(313),
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The nsaoer od" tno biesecprr iabisnotcit lintu sgtneit lsersut rea livba"leaa si etciorcrn is uceaebs we dlayaer ehav a rmga iasnt htta whsso ee-argvmtgain opccdicloi ni apisr. Tihs si eNseisari .aoreohoergn ,oS no dnee ot iawt orf test tssreul eomc c.bka

eTh sQtme- iatgstn ttha Tgnis"et orf Narsisiee nad imlCdyhaa" is ed"oerdr rafet ayardel iavngh endo het mraG istna semes to eb a d.tcsirator

misterdoctor69  I think even in a situation when you don't have the results yet, you'd still prescribe antibiotics just based on history and patient presentation. +  
misterdoctor69  In THIS situation** +  

submitted by hello(313),
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The aosner "od nto cperbeirs cobnatiiist ltuin ttgnsie lteruss rae veba"ialal is rntirocce is bcausee we ldreaay veha a mrag atsni ttah swsoh ganmterav-ieg lcdcicopio ni rsp.ia hiTs si isierNesa roneaeo.horg S,o on nede ot wita fro ttse sserult come ab.kc

Teh Qtme-s tntsiga ahtt Teit"gsn rfo aseeisNri nda a"lmChdaiy is "eedrodr tefar dyareal hinavg nedo the amrG sitan msese ot eb a astiotdcrr.

misterdoctor69  I think even in a situation when you don't have the results yet, you'd still prescribe antibiotics just based on history and patient presentation. +  
misterdoctor69  In THIS situation** +  

submitted by neovanilla(39),

For those curious why it's not D, the way I reasoned it out was that 1. they were referring to opioids, so 2. withdrawal would be

Diarrhea (opposite of constipation that they feel) + nausea Mydriasis (opposite of the miosis) Piloerection Seizures are rare, and they're more associated with alcohol (and also benzos) You may get mild hypertension

misterdoctor69  The choice said "Narcotic pain medication" not withdrawal to the narcotic pain meds. Adverse effects of narcotics would be constipation, miosis, and respiratory depression. +  

submitted by dickass(88),
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Rbmemree s,ikd GFR dorcseorpns tiwh ltSa ,ooricsr)teocimai(lnd argSu ccrcosiuti)og(do,l dan Sex oan.den)(rgs

misterdoctor69  Thanks @dickass, not sure why you got downvoted :( +  

There can be confusion between two options:

Placement of the central line via left internal jugular vein can cause damage to thoracic duct and Placement of pulmonary artery can cause damage to right lymphatic duct. However, chyle [fat + lymph] in thorax is usually caused by the damage to thoracic duct because this duct originates from abdomen so it contains fat along lymph. Thus, central line to left internal jugular vein will be more likely to cause chylothorax


misterdoctor69  The question also mentions that there is dullness to percussion at the LEFT base of the chest and that there is substantial flui in the left pleural cavity. So we can eliminate R-sided structures such as the R subclavian vein. +3  

submitted by sherry(29),
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hiTs is teh docsne tseb cehoci I asw anong keta nrudgi eht m.exa I hotghtu eAg asw rbetet inesc AF idieadctn reeedsadc egeostnr and dlo ega rae teh asroens rof nboe pinse.trroo Can smdyoebo plnxaei to em why eAg ocdul ont lboyspis eb eht naw?ers

kard  I solve it like this: So age is 70 (already, nothing we can do to change it), is asking about a predictor of success in the Rehab process (So basically, what this patient did in matter of activity, life style, etc. to have a Good rehab process). So From all the answers the, Activity level is the most likely choice because of the, increase in Bone density(Specially Weigh bearing) and OsteoBlastic activity. +6  
misterdoctor69  But bu that logic: just like you can't do anything about age, you also can't do anything about activity level BEFORE the fracture right...? +3  

submitted by stepwarrior(21),

You should find out whether or not she wants her parents to know first

misterdoctor69  She's a minor though. +1  

submitted by hayayah(1079),
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deHnapuedinicr- hmoypbertocainot TH()I si eth ovpedenltme fo gGI dbnosiatei gitnasa pnearih unbod aletetlp focatr 4 F)P(.4 ydnbi-nhro-iAPt4Faep ecpmlxo avsatctei tstplelea Ž bthssoriom nda par.hoomttiobcyen ishHget srik htiw aucondfnarttei phe.inra

drw  could you also help to understand: 1) could anti-heparin-PF4 complex be also called anti-PLT antibody? 2) PLT reduction is due to both PLT thrombosis consumption and elimination in the spleen, then why hypersplenism is not correct? +  
charcot_bouchard  hypersplenism means bigger spleen eating everything. thats not the case here. here spleen is normal. autoimmune cause +  
benitezmena  Yes I dont understand why the called them Anti-platyelet antibodies and not specifically Anti-heparin bound to PF4 on platelets. Its just not the right antibody +2  
benitezmena  Antiplatelet antibodies would be for ITP, but also anti-megakaryocyte antibodies would also be for ITP. +1  
misterdoctor69  As an aside, pregnancy is a hypercoagulable state which caused her DVT in the first place +1  
cport12  If anyone else was freaking out about the word hemodilution basically it just means that there is a decreased concentration of cells and solids in the blood resulting from some other gain of fluid. With normal pregnancy (not HIT), blood volume increases, which results in a hemodilution. +  

submitted by dickass(88),
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:nefmaeloicnecN “Do no r”.hma

venE if hte etiantp nwtas to die, I

champagnesupernova3  FA says you cant assist suicide but you can prescribe pain medication which they can conveniently overdose on +1  
dickass  "Physicians may, however, prescribe medically appropriate analgesics even if they shorten the patient's life." (wink, wink) It's vague, but I guess the main point is to let the patient have relief, side effects no longer important. I still don't think you can just give the patient a bottle of benzos though. +1  
raga7  FA 2018 PG 260 +  
misterdoctor69  FA 2020 p. 268 +  

submitted by xxabi(259),
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Tish si a aosglhtloysr tcud ycs.t ehT alootlsrgys tcud aym istreps nad etlrus in a slroystlgoah duct ystc ccrrng(oiu ni meliidn arne dyhio beon or ta the aesb fo teh o)en,tgu uhts lilw slalcyliasc omev up with olwgswilan or otngeu o.rnouptsir

Teh raofnem cucme (of hte enutgo) si eth loarnm rnmetna of het stosryaglloh ucdt

lilyo  I got it wrong though because the question clearly asks what does this structure (thyroglossal duct) DEVELOP from, not this structure eventually develops to form which structure. If it asked that then I would have picked option A but because it didnt that was the first option I crossed out. +16  
misterdoctor69  It was a poorly worded question no doubt. But when they say "endoderm of foramen cecum" they're referring to the endoderm which is a primitive structure. The "foramen cecum" part is just a modifier that is added to describe what that endoderm would eventually become. +  
lovebug  FA 2019, page 322page! +  

Phase 3 examines whether or not the new drug is more efficacious than the gold standard treatment. As the stem gives no information as to if the drug is compared to other treatment or a gold standard, this is a classic example of a poorly written NBME question.

misterdoctor69  But just from knowing that the phase includes a LARGE # of patients, that alone should tip you off on it being Phase 3... +1  

submitted by madojo(177),
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I dnot' wnko fi iths saw het grith wya i hghutot uabto ti btu i mdemreebre K A..H..thCLe intghs thta cuase oiidanoatlvs in saelletk sumcel

C - o2C, H - H+, A- noeiads,ne L - attecla -K K+

drdoom  This is great; these are all proxies of catabolism, i.e., "net" ATP consumption! (ATP->ADP) +1  
drdoom  Potassium might be the one that doesn't seem to fit but recall that cells have an H+/K+ antiporter: cells can act as a "sink" for high blood H+; they "take up" H+ (from blood, into cell) but "in exchange" they have to put out a K+ (to maintain a normal electro-gradient). So, as blood acid starts to creep up, cells actually "attempt" to bring it back to equilibrium by sucking up H+ (and putting out K+, which, as you surely recall ;), is the predominant cation within cells). +3  
misterdoctor69  @drdoom, would you also venture to say that there is increased Na+/K+ ATPase activity in an increased metabolic state which might also contribute to greater K+ efflux into the blood? +  
drdoom  @misterdoctor69, no. Potassium flow is driven by its chemical gradient (from inside cell, where its concentration is high, to outside). If K+ efflux is increased, the best culprit would be the H+/K+ antiporter (which “takes up” a proton, but has to “surrender” a potassium, in an attempt to remove acid from the blood — acidic blood, of course, being an inevitable outcome of revved metabolic state: net ATP consumption & high CO2 production). +  

submitted by yex(102),
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iccAgndro ot jloaG:n 2"1B )amclnboa(i ash cltaob in it. lrcgianuiCt fmor of ofetla si olleatrtotehhdtafy.ymer sPupreo fo bionlacma B)(21 is to ktae eht eyhmtl ugorp fof fo yolltr.efmadrotteyhahte Tneh ’tsi cellda dtyfteoraal.rteho If uoy o’ndt tge eht tlhyme uopgr off of ateol,f oyu llwi nto maek .AND ,oS fi yuo rea 12B d,fe uyo cat’n get het teylhm pougr ffo dan atnonc emka D.NA fI uyo era dfe in fole,at oyu nat’c amke D"N.A

misterdoctor69  lmao +  

Beneficence: health care providers have a duty to be of a benefit to the patient and should take positive steps to prevent and to remove harm from the patient.

Consent for minors (FA2020 pg 265): Consent should be obtained from parents, except for Emergency Medicine.

This is a case where the Principle of Beneficence is given priority over the principle of respect for the patient's autonomy. In Emergency Medicine, the patient is incapacitated by the grave nature of accident or illness, we presume that the reasonable person (in this case, the patient's parents) would want to be treated aggressively, and we rush to provide beneficent intervention by stemming the bleeding, mending the broken or suturing the wounded.

So by the Principle of Beneficence, the surgery was indicated and by the same principle, the doctor proceeded without permission because it was a case of Emergency Medicine.

misterdoctor69  What I found strange about the question was that the parents were even contacted for consent to begin with..when, as you clearly stated, consent isn't needed for emergency medicine. In the hypothetical scenario where the parents were able to be reached and they said, "No, don't do the procedure," what would happen next? +2  

submitted by shiv360(0),

Aldo is primarily regulated by ATII. Cortisol is primarily regulated by ACTH. However, since cortisol can also activate aldo secondarily, it works. However, I believe that ADH should not have been answer choice however since no lung biopsy findings were reported so we can't really distinguish between SCC vs. NSCLC

misterdoctor69  the question literally says small cell carcinoma though +  

submitted by gonyyong(108),
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The kid sha osinamecyatg edu ot tubyrpe x(ecses tesnestorote → gT sseretihn)o sgeo wyaa alyltunra etpa(lyanrp in 21 ot 81 tnmoh)s

I nikht ouy ndto' ahev to do bodol tsste eecsabu eh ash omrnla luesxa meltdnpeeov ofr sih aeg adn reeht rea no oerht i?snsg

osler_weber_rendu  How does telling an "embarrassed kid" that he will have big tits for 12-18 months help?! +29  
howdywhat  my exact thought, telling him that it will last for somewhere around a year and a half doesnt seem so reassuring +1  
suckitnbme  I thought it was reassuring in that the kid is being told this isn't permanent as well as that this isn't something serious. It's important to inform him about the prognosis. +8  
thotcandy  "don't worry your gynecomastia isn't permanent, but the mental scars from the bullying you will receive in HS definitely will be :) good luck!" +4  
therealslimshady  What is the gynecomastia is from a prolactinoma? +  
misterdoctor69  @therealslimshady the gynecomastia is from the sudden surge of testosterone during puberty being converted into estrogen => more breast tissue. +3  
mnunez187  My breasts are not rubbery nodules, thank you very much! +  

submitted by mdrahimi7(-5),

I know most of us think that it is wrong that platelet adhesion is decrease by platelet and we are true but actually the answer means platelet adherence to other platelet is decreased( platelet aggregation ) not platelet ahesion function of clot formation ( sticking of platelet to non-platlet surface).so question means platelet adherence to each other I hope u got the answer 🙂.

misterdoctor69  Yeah they should have just put platelet aggregation instead of us having to try to read their mind that they mean platelets adhering to other plateltes lmao. By definition, platelet adherence refers to platelets sticking to collagen, not each other +1  

submitted by brethren_md(90),
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omrtu fo enPail dGnla e)lniamaP(o cuessa riPdanua rSnedyom vlceirt(a aezg ylsap)

neonem  Due to compression of the superior colliculus in the tectum, I believe +8  
wowo  FA2019 p516 +4  
misterdoctor69  FA2020 p528 +1  
qiss  tectum as in the superior colliculus +  

Just adding on- Xray of large muscle groups would help in diagnosis of cysticercosis since cysts are calcified, in trichinella they are not. I think i'm the only one who got this wrong :/

misterdoctor69  Maybe so, but I think that if we get any questions concerning cysticercosis, it would be neurocysticercosis, so you'd do brain imaging instead... Additionally, as per the CDC: muscle cysticercosis is usually nontender?: +  
brs  I think everyone who has watched House M.D. S1 E1 gets a chance to make it wrong. +  

submitted by haozhier(18),

How do you guys know about this? I chose stool O&P...and muscle biopsy is not mentioned anywhere...

misterdoctor69  Sketchy micro! +  

submitted by lsmarshall(416),
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PCA esortk can acues "aisopngpooras" chhwi is eth niiybilta to ierzcoeng mlaifair afsce. usCaed by rliblteaa inoless fo sviaul nstocaoaiis sa,era chwhi aer stutidae in teh rornieif etitocmprlcpaooi xecort f(fsmoiur y)rgu.s heT iaibtyl ot aemn sprat of the efca ..,e(g nose, huo)mt or itfidnye iuaslidivnd yb rehot secu e(g.., lgtinho,c c)iovse is etfl .tiatnc

titWouh ionwgnk tta,h emmgeinrebr ciclpotai lebo is vvdelino ni ilsva'u fufts' aobl,dyr nnicgulid egiam ssercipgno adn hist ntetiap is ngvaih sisesu wiht endnsgtuanird agemsi hdouls be huegno ot etg to het a.rnwes

gonyyong  Lol I guessed it exactly because of that +4  
sympathetikey  Never heard of that one before. Thanks! +1  
karthvee  This is not prosopagnosia, but instead a case of apperceptive agnosia. Wiki: "...patients are more effective at naming two attributes from a single object than they are able to name one attribute on each of the two superimposed objects. In addition they are still able to describe objects in detail and recognize objects by touch." Although, lesions tend to be in the occipito-parietal area so PCA again is the answer! +3  
misterdoctor69  I actually think it's both prosopagnosia AND apperceptive agnosia. She is neither able to recognize her mother's FACE nor is she able to recognize objects w/o the help of other senses (apperceptive agnosia) +  
nifty95  Yea couldn't remember the exact name but I just thought of three pathways (visual, somatosensation, and auditory) all converging somewhere/processor (probably somewhere in the temporal lobe...hippocampus?). Beyond the point, the pathways converge to an area which culminates in recognition. Cut off one of the routes (in this case visual), the other two will still work. How is visual cut off? By the PCA not supplying the area leading to neuronal death resulting in varying loss of visual function depending on the area in the occipital lobe. +1  

submitted by brethren_md(90),
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Oeraccnhoc ouluVsvl aiv lfaeme ylclka.fb clakB efil,s lkcab nski sdo,unle "labkc higts" kaa( Blnesdisn). ntuesQio mets heer sieedcrsb the lkbac oelsnud enes ni Oencrh.coca

linwanrun1357  There is no black in the stem~~!! +5  
misterdoctor69  nodules can be hypo or hyperpigmented supposedly! +1  

submitted by sangeles(9),
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To me it ndsous oerm ilke vsnue el.impsx heT sotm ocmnom ryilplcaa ntrfmlaoiamo is evnus mpslxie, hwich cfafest eomr nhat hfal of nifat.ns vNeus i,esxmlp ro onmasl“ pth”a,c liseosn rae pn,ik ldinee-fldi cpaesht htta dnte ot cocur ni ednimil ,licnsoato ostm fqeytlnrue on the pena fo eth cken, lalgbela, ylsee,id nspi/se,ol salp,c dan arlcsa enigor tHlscoarilyi, ooulillqac setmr shuc sa ts“okr bet”i e(a)pn and enl“ag ski”s afb/logedhe)aela(rl eredfrer to nseuv melspix sosenil ni uiaprclatr tcnlaiaamo gir.oens Ulekin WPS nad msot rtheo ralcvsau om,onftmiaalsr otsm vsnue xslpeim liesnso esrergs iwntih eth tsifr 2 rayes of eilf ilCaciln riifnfeintdoate of snveu eslixpm orfm WPS, cslelyipea on iailtin ent,taneirspo acn eb fi.ldcftiu siLsneo twhi iegtrlh kpni rl,oco eiimdln taolci,no nda titidcsinn rdeobrs ovarf usvne slmep.xi tsMwpoicipt//m8../lC.51c3hmPe/./h/twcb6n9vslnnarwg5i:

suckitnbme  I agree that this nevus simplex and not a strawberry hemeangioma. Of note, nevus simplex lesions are flat lesions formed from dilated capillaries. Lesions on the face tend to regress while lesions on the back of the neck typically do not. +1  
misterdoctor69  The main thing that bothers me about this question is that if it is indeed nevus simplex, it's definitely a very non-typical presentation. Nevus simplex most commonly occurs on he back of the neck/midline locations plus they are pink in color. The lesion described in this question is purplish (not pink) and it appears on the right side of the face (ie. neither back of neck nor midline). We can definitely rule out nevus flammeus because that is only seen in the setting of Sturge-Weber syndrome, which this patient has no signs of. We can also rule out strawberry hemangioma because such a lesion would be raised, not flat. +5  
osteopathnproud  To add to that, I guess in the NBME world you can not have a nevus flammeus if there is no Sturge-Weber syndrome, in the real world most nevus flammeus are not associated with Sturge-Weber syndrome, but if a patient has Sturge-Weber syndrome then he is very likely to have a nevus flammeus +  
larryd  I think this is an infantile or a congenital hemangioma, based on the fact that they can also be flat/plaque-like, and are found in greater frequency in girls (like this pt). +  

submitted by zbird(2),
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ishT neptiat ash yiDal-eTstp I ATR hwcih si adpxenlie by rolmNa uSmre Annio gpa 8() bMtlieoac iosisadc htwi her viiesotp yauirrn nnoai 5+(ap)g.

krewfoo99  Why would the urine Potassium be so high if it is type 1 ? Shouldnt it be type 2? +  
drpatinoire  @krewfoo99 I think it's RTA2 (Fanconi syndrome), he is losing all kinds of Na, K, Cl which should be reabsorbed in PCT. +  
misterdoctor69  @Drpatinoire: it can't be RTA2 because the urine anion gap (UAG) is positive (+), which implies that the patient is unable to secrete H+ (via NH4+, which couples w/ Cl-). RTA2 on the other hand has a negative (-) UAG because RTA2 affects only the proximal tubule's ability to reabsorb bicarbonate (i.e. H+ secretion via NH4+ in the distal convoluted tubule is unaffected). +