CASE PRESENTATION: A 41 year old female with a past medical history of CAD s/p PCI, HTN and chronic back pain presented to the ER with constant and diffuse chest pain radiating to her back. Her pain was a 20/10, worsened with movement and relieved with oxycodone. She had dyspnea at rest but denied fevers, chills or cough. She was given aspirin and nitroglycerin in the ambulance. In the ER, vitals were: temp of 37, RR 30, HR 130, O2 sat of 93% on room air. She was slightly confused, diaphoretic, using accessory muscles of respiration, but the rest of her physical exam was unremarkable. An EKG showed no acute ischemia and a troponin was normal. An ECHO and a CTA thorax were normal. An hour later, she became more altered and developed bilateral hearing impairment. Labs were significant for an anion gap of 18 with a bicarbonate level of 16. Further history revealed the patient was taking aspirin hourly for the past three days for a toothache. A salicylate level was 64.5 and an ABG showed a pH of 7.46 with a pCO2 of 20. She was placed on a sodium bicarbonate drip and emergently dialyzed, and as her salicylate levels decreased, her tachypnea and chest pain diminished. When her levels normalized, her chest pain and other symptoms completely resolved.