HPI:

• 69 yo M, PMHx Lung Adenocarcinoma recently started on chemo with first session 2 weeks ago p/w chest discomfort and SOB
• Cough, generalized weakness and decreased appetite
• No fevers, N/V/D

Physical Exam:

• BP 180/93  | Pulse 80 | Temp 97.4 °F | Resp 27  | SpO2 96%  
• Appears uncomfortable, diaphoretic
• Markedly tachypneic with pursed lipped breathing. Lungs clear

Triage EKG:

Cardiac POCUS:

• Mild-moderate pericardial effusion without tamponade physiology 

DDx: 

• Acute pericarditis, ACS, PE, CHF exacerbation, PNA

Initial workup:

• Cr 16, BUN 200 (nml kidney function 2 weeks ago), K > 6, HCO3 5, AG 35
• hsTrop 96
• Phos 16, uric acid 19

Management:

• Given calcium gluconate, 5U insulin IV with D50
• Nephrology consulted - emergent hemodialysis for acidosis and uremic pericarditis possibly in the setting of tumor lysis syndrome vs medication (chemo) adverse effect

Take home points:

• Tachypnea with clear lungs → ACIDOSIS
• Diffuse ST elevations: pericarditis
• Indications for emergent dialysis: “AEIOU” - acidosis, electrolytes (K > 6.5), intoxications, overload w/ fluid, uremic pericarditis / encephalopathy
• Tumor lysis syndrome: typically seen with hematologic cancers and more rarely in solid tumors in setting of recently starting chemo
• Characterized by hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia
• IVF, allopurinol, rasburicase, dialysis