What screening labs are recommended for a 49-year-old female with complaints of fatigue and joint pain, history of anemia due to menorrhagia (heavy periods), positive Antinuclear Antibody (ANA) test in the past, and left foot pain possibly due to a bunion?

From the Guidelines

For a 49-year-old female with fatigue, joint pain, history of anemia from heavy periods, previous positive ANA, and left foot pain with possible bunion, I recommend the following screening labs: Complete blood count (CBC) to assess for anemia and inflammation; comprehensive metabolic panel (CMP) to evaluate organ function; erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to measure inflammation; iron studies including ferritin, iron, TIBC, and transferrin saturation to characterize the anemia; thyroid function tests (TSH, free T4) as thyroid disorders can cause fatigue; vitamin D level since deficiency can contribute to joint pain; rheumatologic panel including ANA with reflex testing, rheumatoid factor, and anti-CCP antibodies given her joint symptoms and previous positive ANA; and urinalysis to screen for kidney involvement. These tests will help evaluate the patient's anemia, assess for autoimmune conditions that could explain her joint pain and fatigue, and rule out metabolic causes of her symptoms. The foot pain should be evaluated clinically and with X-rays if a bunion is suspected, as this is likely a separate orthopedic issue but could be related if there's an underlying inflammatory arthritis, as suggested by the European League Against Rheumatism recommendations for the management of early arthritis 1. Given her previous positive ANA, it is essential to include a rheumatologic panel with reflex testing to further characterize any potential autoimmune condition, in line with international recommendations for the assessment of autoantibodies to cellular antigens referred to as anti-nuclear antibodies 1. Additionally, considering her symptoms and the need for a comprehensive assessment, the approach should align with guidelines for managing immune-related adverse events, which include a complete rheumatologic history and examination, and consideration of autoimmune blood panels and imaging if necessary 1. The primary goal is to identify any underlying conditions contributing to her symptoms and to guide appropriate management to improve her quality of life and reduce morbidity and mortality.

From the Research

Screening Labs for Anemia and Iron Deficiency

The patient's history of anemia from heavy periods and positive ANA in the past, along with current complaints of fatigue, joint pain, and left foot pain, suggests the need for a comprehensive laboratory evaluation.

• A complete blood count (CBC) with reticulocyte count is recommended as the initial step in evaluating anemia 2, 3, 4.
• The CBC will help categorize the anemia as microcytic, macrocytic, or normocytic, and the reticulocyte count will indicate the presence of reticulocytosis or reticulocytopenia.
• Additional tests that may be useful in evaluating iron deficiency anemia include:
  • Serum iron level
  • Total iron-binding capacity
  • Serum ferritin level
  • Reticulocyte hemoglobin content (CHr) or reticulocyte hemoglobin (Ret-Hb) as a screening test for iron deficiency anemia 5, 6.
• Other tests that may be considered based on the patient's symptoms and laboratory results include:
  • Peripheral blood smear
  • Vitamin B12 and folate levels
  • Lactate dehydrogenase, haptoglobin, and bilirubin levels 3.
• The use of CHr or Ret-Hb as a screening test for iron deficiency anemia may be particularly useful in this patient, given her history of anemia and heavy periods 5, 6.