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Welcome to misterdoctor69’s page.
Contributor score: 40

Comments ...

 +0  (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

 +7  (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

 +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.

 -1  (nbme24#47)

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

 +0  (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 +

Subcomments ...

submitted by step1soon(45),
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ookL ta rwhee hte ucsps aer itgnpnoi → arpsduw treerhoef fi cspsu wree wronawdd → tenh amtlir vevla woldu be eth thrig wrnesa

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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Mxeid esunov xoegyn tneinos is eth aountm fo onexyg uondb ot mobglineoh sa it retsnur to the ghirt dsie fo eth heatr aertf einvrgtla ot eth ut.sesis

cDesraeed xgyeon vdeyierl to eth ssutsie edu ot redsecead adcrcia utoupt easdl ot eht ssiutes xrcatginte mroe eynxog morf eht sgnspai CBsR anth hyte nmrolyal lu,wod hiwhc decreasse the lralevo dxmei oenusv eoyngx itnnseo.

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(1056),
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LHLPE ordsmy:ne ty Hmvi eoElsdselae ivreL szweenmLy o .ltPsteela

A isanntaotfemi of versee aicpera.lpems doBol remsa shsow cshttsociyes. Cna elda to ICD dna atehicp hmssoauaa pturslmcbae Ž urreupt Ž eveesr nhtops.yoein

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(34),

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(301),
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heT snoaer do" otn prsbrieec itstbiconia iulnt nttgise rtlseus rae l"beaiaalv si rneotrcci si aebecus ew rledaay vhea a agmr sanit atth woshs aveg-agtmenir pclcioodci ni rais.p ishT is eiNrseasi gooeoahre.rn So, on nede to iatw rof sett esutlrs cemo .bakc

The m-stQe ainttgs hatt "tsneiTg fro riaNsiese and C"aaydhlim si derer"do traef yalaedr vghnia edon teh Garm tnais emess to eb a .oatirtsdcr

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(301),
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hTe onarse o"d nto cierepsrb sctbaoniiit intlu tgneits suletrs era elv"ibaala is treorcinc si baeescu we aydlear evha a rgma naist atht wsohs gieavaenr-mgt ocdiolccip in ra.spi siTh si eeNiisars ngeoorehro.a oS, no edne ot atwi rfo etts lrtusse cemo .ckab

heT mQ-set anttisg atht Tgin"tse for irNssieae nad hmCadayl"i is "dodeerr rfeat laedray hvnagi onde hte rGma tiasn sseme to eb a tsi.tdroarc

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(35),

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(84),
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mrebeeRm dki,s FRG rceopnssdro thiw tlaS iari)en,l(dcoiotsrocm urgaS c)ldsou,r(icotciog and xeS ().eagnrnsdo

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(28),
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hisT is eth sendco tbse oihcec I asw nagon aekt dunirg eht I ohuhtgt Age aws ettebr cnsie AF itdidcaen rsdaeecde resogetn dan lod ega are eth saesnor fro nobe ptioesrron. naC domyoseb epaxnli to em hyw Age odclu tno lbpsioys be het seran?w

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(20),

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

misterdoctor69  She's a minor though. +1  

submitted by hayayah(1056),
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cnidnueadeHp-ir tehotamrobpnyoci )TI(H is eht neoemvptlde fo IGg nisbodetia ngsaati hnepari onubd eltaptle ftarco 4 ).(F4P nAdbpo-tnFP4-eiiayrh moecxpl tacitsvea eslpleatt Ž hosobmstir adn ey.micotpbthonora Hisegth ksri ithw nnaatdutofceir pnr.ieah

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(84),
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nanocem:ifeleNc D“o on”h

vneE if teh tatinpe ntaws to ,ide I ss.ueg

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(251),
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hisT is a arlyosthglos tcdu The slgotraosyl dcut aym rpsesti and euslrt ni a tlgsrshlaooy cutd ysct ocrrugicn( in iemldin anre oihyd beon ro ta het saeb of the ug,)eton suth lwil clsyllicsaa vmoe up hwti iowswallgn ro ongtue op.isrnourt

The rmefoan mcuec fo( eth )nouteg si hte nralom rnmenta fo the saloysglohrt dtuc

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. +15  
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(160),
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I don't nokw fi sthi aws the irhgt ywa i othhtug uobat ti but i eeederrmmb KAetC Hh....L hgitsn thta sueac nasoliovdtai in slkeleta eumcls

C - Co2, H - H,+ -A esnenaio,d L - taelcta -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(93),
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cocgnrdiA ot ajGo:nl 1B2" locanim)b(a has caotlb ni .ti ingcruCitla omrf fo ltaoef si yaooldmtheeefh.latttrry ePrsopu fo banmiloac 1)(2B is to etak het ymhetl orgup fof of otetlyfaro.aedemtrlyhth eTnh si’t declla rlrdaeteyth.tofao fI uoy n’tdo egt eht tehyml prgou off of ,elfaot uyo will not ekam A.ND S,o if uyo rae 1B2 ,edf uoy ’actn egt teh thymle rgoup off adn taoncn make A.DN If oyu ear edf in lfoaet, uyo tcna’ kmae "D.NA

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? +1  

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(101),
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ehT dki sha ecoigmtaynsa deu to pbryute execss( oeonerststet → teosnhgi sTer) egos yaaw luratyanl ae(paltnrpy in 21 ot 18 tsno)hm

I thnki yuo dnt'o hvae to do dlboo etsst ucaeebs he hsa romlna exusla epdoevlmetn for shi ega adn eehtr rae on orhet gss?in

osler_weber_rendu  How does telling an "embarrassed kid" that he will have big tits for 12-18 months help?! +28  
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!" +3  
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(87),
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motur of Pleain ndGla a)lonPemai( cssuea nauPidar oymnSedr (atrlcevi zega ylp)sa

neonem  Due to compression of the superior colliculus in the tectum, I believe +8  
wowo  FA2019 p516 +3  
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?: +  

submitted by haozhier(15),

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(393),
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ACP ektsor cna ecsau "pporaosgasino" ciwhh is teh ntylbiaii ot geeiozcnr amrilafi cefas. duCsae yb ilbtaarel nolsise of vulsai sicnisaatoo a,asre ichhw rae aedtiuts in eth ifnoirre itlpitocopoercma xocetr ri(fmuofs )rguy.s eTh ltiybai ot eanm ratsp fo eth eafc (.g.e, o,ens tu)ohm ro diieftny lsiuidivdan by ehtro csue (e.,g. gilco,htn )sciove si tefl nttc.ia

Wotithu noiwkgn th,ta mmgernbieer ipicctalo olbe si iovndlev ni 'lsuvia uf'tfs ydb,aolr cndiuignl eigma irpncoegss adn sthi aettpin is agihvn siusse ihtw tiaddnuesgnnr smgeai holuds eb ehugno ot gte to het .wrasen

gonyyong  Lol I guessed it exactly because of that +3  
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(87),
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eOcornccha uVlousvl avi feemal bllyack.f akBlc fesil, labck nisk deso,uln cal"bk is"htg ka(a nid.snle)sB Qiuteosn etsm heer secdesirb the klcba sudoeln nsee in hraOcencco.

linwanrun1357  There is no black in the stem~~!! +4  
misterdoctor69  nodules can be hypo or hyperpigmented supposedly! +1  

submitted by sangeles(9),
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oT me it sondsu rmoe keil vseun slxp.eim The most omcnom lpaylicar iatmnofralmo si ensuv imsplex, ichwh fscftea eomr atnh hlfa fo na.nitsf sveuN xem,psil or o“nmasl ”phc,ta loseins era n,kpi lie-dnefidl htspeac ahtt ndte to curco ni lndeimi oclan,isto mots teenyquflr no teh pena of het ,nekc llb,aaleg yle,dies ie,pss/nol s,clpa and arlasc negori H,ilctoyaslir loaucqolil tmesr hcus sa k“srto ”eitb npe)(a adn g“alen s”isk efalhlg/el)ebarad(o edrefrer to vnsue lepsmix snsleio in ircaurtpal acomaianlt nUkiel PSW adn omts treho vucrsala ,nsoailatommrf stmo neusv ismplxe eslnsoi esrresg iwtihn eth sitfr 2 syrae of leif lilCcain fittndoiefreain of eunvs iexlmsp rfmo PS,W yiaplclese no atiilni re,npatentois nca eb .tliufcdfi noisesL hiwt triehgl nkpi coorl, minleid ico,onatl and dcntiiitns bdresor vaorf usnev sexpml.i e/o//w.ci5tmMapwtsmhCiib3.65hn:grv.n/cl1/c8p9.wstl/nP

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 +  

submitted by zbird(2),
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iThs aptenti ash -tliysDTaep I ATR ihcwh is deipxaenl by amNorl erSum inoAn gap )8( tMocealbi diacsios wthi hre pisvtioe raiurny noain gp(5+).a

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). +