What is the appropriate inpatient work‑up and treatment plan for a 61‑year‑old woman with known cardiac disease, type 2 diabetes mellitus, chronic non‑healing wounds, severe chronic obstructive pulmonary disease, leukocytosis with neutrophilia, elevated creatine kinase, hypomagnesemia, and vitamin D deficiency?

Inpatient Management of a 61-Year-Old Woman with Multiple Comorbidities and Elevated Creatine Kinase

This patient requires immediate hospitalization for comprehensive evaluation of her elevated creatine kinase (526 U/L), leukocytosis (WBC 12.8), and poorly controlled diabetes (HbA1c 10.0%), with priority given to ruling out myocardial injury, infection, and optimizing her multimorbidity management.

Immediate Diagnostic Workup

Cardiac Evaluation (Priority #1)

• Obtain troponin levels immediately to evaluate for myocardial involvement, as elevated CK with cardiac disease history requires exclusion of acute coronary syndrome or myocarditis 1
• Perform 12-lead ECG looking specifically for ST-segment changes, T-wave abnormalities, or new conduction abnormalities that could indicate ischemia 1
• Order transthoracic echocardiogram to assess left ventricular function, wall motion abnormalities, and evaluate for heart failure given her cardiac disease history 2
• Check BNP or NT-proBNP (her BNP of 27 is normal, which argues against acute decompensated heart failure) 2

Elevated CK Workup

• Repeat CK with CK-MB fractionation to determine if elevation is cardiac or skeletal muscle origin 1
• Obtain comprehensive metabolic panel including AST, ALT, LDH, and aldolase to assess for myositis or rhabdomyolysis 1
• Check inflammatory markers (ESR, CRP) to evaluate for inflammatory myopathy 1
• Assess for muscle weakness through formal strength testing, as weakness is more typical of myositis than pain alone 1
• Review all medications for statin use or other myotoxic agents that could explain CK elevation 1

Infection Evaluation

• Obtain blood cultures × 2 sets given leukocytosis (WBC 12.8) with neutrophilia (8.89) and chronic wounds 3
• Perform wound cultures from all chronic wounds to identify pathogens and guide antibiotic therapy 3
• Check urinalysis and urine culture as urinary tract infections are common in diabetic patients 3
• Obtain chest X-ray to evaluate for pneumonia given severe COPD history 2

Metabolic and Nutritional Assessment

• Correct hypomagnesemia immediately with IV magnesium sulfate 2-4 g over 4 hours, then oral supplementation, as low magnesium (1.4 mg/dL) worsens cardiac arrhythmias and glycemic control 1
• Initiate vitamin D supplementation with 50,000 IU weekly for 8 weeks given level of 28 ng/mL (deficient) 3
• Obtain comprehensive renal function panel including creatinine, BUN, and calculate eGFR to assess kidney function in context of diabetes and cardiac disease 1

Immediate Treatment Priorities

Glycemic Control

• Transition to insulin therapy with basal-bolus regimen targeting glucose 140-180 mg/dL inpatient, as HbA1c of 10.0% indicates severe hyperglycemia requiring intensive management 1, 4
• Consult endocrinology for optimization of diabetes management and consideration of SGLT2 inhibitor once stable, which provides cardiovascular, renal, and glycemic benefits 1
• Hold metformin temporarily if present, given elevated CK and need to rule out lactic acidosis risk 4

Cardiovascular Optimization

• Ensure patient is on guideline-directed medical therapy including ACE inhibitor or ARB (for cardio-renal protection), beta-blocker (for cardiac disease), and high-intensity statin (for ASCVD) 1, 4
• Target blood pressure <130/80 mmHg using RAAS blockade as first-line therapy 1
• Avoid NSAIDs completely as they worsen heart failure, increase blood pressure, and cause renal toxicity 1

Infection Management

• Initiate empiric broad-spectrum antibiotics if clinical signs of infection are present (fever, wound purulence, systemic toxicity), tailored to wound culture results 3
• Ensure tetanus prophylaxis is current for chronic wound management 3

Electrolyte Repletion

• Administer IV magnesium sulfate 2-4 g over 4 hours, then transition to oral magnesium oxide 400 mg twice daily 1
• Monitor and correct other electrolyte abnormalities that may contribute to cardiac arrhythmias 1

Monitoring Plan

Daily Assessments

• Monitor CK levels daily until trending downward; if CK continues to rise or exceeds 1,000 U/L, consider rhabdomyolysis and aggressive IV hydration 1
• Check troponin every 6-8 hours × 3 if initial troponin is elevated to establish trend 1
• Monitor renal function daily (creatinine, BUN) given diabetes, cardiac disease, and potential for contrast exposure 1
• Assess muscle strength and pain daily to detect worsening myopathy 1
• Monitor blood glucose every 4-6 hours with insulin adjustment protocol 4

Critical Decision Points

• If troponin is elevated with ECG changes: Activate cardiology consultation for possible cardiac catheterization 1
• If CK >1,000 U/L with myoglobinuria: Treat as rhabdomyolysis with aggressive IV hydration (200-300 mL/hour) targeting urine output >200 mL/hour 1
• If muscle weakness progresses: Consider EMG, muscle MRI, or biopsy to diagnose inflammatory myopathy 1
• If blood cultures are positive: Extend antibiotic course and evaluate for endocarditis with transesophageal echocardiogram 3

Common Pitfalls to Avoid

• Do not assume CK elevation is solely from statin use without ruling out cardiac injury, especially with her cardiac disease history 1
• Do not overlook infection as a cause of leukocytosis in a patient with chronic wounds and diabetes 3
• Do not use erythropoiesis-stimulating agents without oncology clearance if anemia develops, given potential malignancy concerns 3
• Do not discharge until CK is trending downward and cardiac injury is definitively ruled out 1
• Do not continue NSAIDs if patient is taking them, as they worsen heart failure and renal function 1

Discharge Planning Considerations

• Coordinate multidisciplinary follow-up with cardiology, endocrinology, wound care, and primary care within 1-2 weeks 1
• Optimize ASCVD risk reduction with high-intensity statin, antiplatelet therapy (if indicated), and blood pressure control 1, 4, 5
• Consider cardiac rehabilitation referral to improve functional capacity and provide structured exercise and education 1
• Ensure medication reconciliation before discharge, including verification of all prescriptions and elimination of harmful medications 1
• Arrange home health services for wound care management and medication administration if needed 1