elevated ck

[ziffy 850]

during routine physical, 35yom presents with elevated ck 3500 ast 100 alt 45asymptomatic but gym day prior-significant?? what next??

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[neurologist]

during routine physical, 35yom presents with elevated ck 3500 ast 100 alt 45asymptomatic but gym day prior-significant?? what next??

What next? Ummm, I dunno. How how about a little more history for starters?

Key items are:
Prior episodes of cramping with exertion? Other exercise intolerance?
Family history of muscle disease?
Weakness or atrophy on exam?
Drug use?
Alcohol use?
Hydration status?
Dark urine? (myoglobinuria)

If he's asymptomatic with no other history as above and a CK of 3500, I'd just have him orally hydrate and recheck CK in couple days (with no trips to the gym in between) to see if it's elevated at baseline.

 

[ziffy 850]

denies drug and alcohol use
denies any family history
urinalysis negative
denies any cramping or exercise intolerance

repeated labs 72 hours later-same results

repeat in a week?

hope there's nothing wrong with this guy coz I know him.

 

[michaelrack]

during routine physical, 35yom presents with elevated ck 3500 ast 100 alt 45asymptomatic but gym day prior-significant?? what next??

What was the indication for checking a CK during a "routine physical"?

Any rash or signs of vasculitis? I would check an ESR/CRP.

I would also verify again with the patient that he is on no medications/herbal supplements.

What is the patient's body habitus? Non-alcoholic steatohepatitis is a pretty common cause of mildly elevated LFT's but it wouldn't explain the CK.

You mentioned the patient was at the gym- any chance of injectable steroids- that could explain both the LFT's and CK.

Was the rest of the rest of the liver panel normal?

Any chest pain?

 

[ziffy 850]

don't really know why the ck was done-i think guy was complaining about gerd

no injectibles-no herbals-lots of cola drinks, including asparatame stuff-professional guy -everything else within normal limits

 

[michaelrack]

don't really know why the ck was done-i think guy was complaining about gerd

Presumably the CK was done to evaluate for a cardiac cause of the heartburn symptoms. Now that the CK came back positive, I think his doc is obligated to fully evaluate for a cardiac cause of his symptoms - EKG, CK isoenzymes, troponin I, CXR, possibly a stress test. Incidentally, cardiac ischemia can result in an elevated AST.
I personally wouldn't get a CK in a person with reflux symptoms (though I might do an EKG), but now that its been done, his doctor needs to follow up on it.

CK isoenzymes would be especially helpful in this case- although not very sensitive/specific, would help in the evaluation of a cardiac vs muscle cause.

 

[ziffy 850]

his doc is sending him to a neuromuscular guy-maybe there's more to it-i'm just an intern-what do I know, but I would probably wait and repeat since there are no symptoms

then again, I guess 3500 seems pretty high

 

[neurologist]

Presumably the CK was done to evaluate for a cardiac cause of the heartburn symptoms. Now that the CK came back positive, I think his doc is obligated to fully evaluate for a cardiac cause of his symptoms - EKG, CK isoenzymes, troponin I, CXR, possibly a stress test. Incidentally, cardiac ischemia can result in an elevated AST.
I personally wouldn't get a CK in a person with reflux symptoms (though I might do an EKG), but now that its been done, his doctor needs to follow up on it.

CK isoenzymes would be especially helpful in this case- although not very sensitive/specific, would help in the evaluation of a cardiac vs muscle cause.

Ugh. That just opens up a huge can-o-worms. CKs (along with ESRs and ANAs) are among the most inappropriately ordered tests out there. Nothing in life is worse than having to chase down an "abnormality" on a lab that never should have been ordered in the first place. If the doc was really thinking "cardiac" he should have got an ECG/troponin/stress test to begin with. Of course, that means the patient should have been parked in hospital or ER for serial troponins (we had a rash of outpatient-clinic-ordered troponins at my last hospital that were driving everyone nuts . . . )

To answer the OP's question . . . a CK of 3500 is not in and of itself alarmingly high. There are even people with "idiopathic hyper-CK-emia" who run in the tens of thousands with no apparent ill effects.