Hemoglobin Decline in Middle-Aged Woman: Iron Deficiency vs. Occult Bleeding

Case at a Glance

A 58-year-old woman presented with a concerning drop in hemoglobin from 12.0 g/dL to 11.1 g/dL over a 24-day period, prompting investigation for potential iron deficiency anemia versus occult gastrointestinal bleeding.

Patient's Story

The patient was asymptomatic, reporting no fatigue, weakness, gastrointestinal symptoms, weight loss, or visible bleeding. The hemoglobin decline was discovered during routine follow-up laboratory work. Her family was particularly concerned about the relatively rapid decline over less than a month.

Initial Assessment

Physical examination was unremarkable with no pallor, lymphadenopathy, or abdominal masses. Vital signs were stable. The patient appeared well and denied any constitutional symptoms. Initial concern centered around the rate of hemoglobin decline rather than absolute values.

The Diagnostic Journey

Laboratory workup revealed: Iron studies within normal limits, Ferritin 22 ng/mL (low-normal range), CRP and ESR normal indicating no acute inflammation, Blood smear showed resolution of previously noted target cells and was now normal, Initial fecal occult blood test (FOBT) was negative. A follow-up 2-day FOBT was ordered for increased sensitivity.

Final Diagnosis

Working diagnosis of early iron deficiency anemia with consideration of occult gastrointestinal bleeding. The differential included hydration status variations affecting hematocrit measurements and early-stage iron depletion.

Treatment Plan

Conservative monitoring approach with repeat FOBT testing. Patient counseled on dietary iron intake and advised to monitor for any developing symptoms. Follow-up laboratory studies scheduled in 4-6 weeks to assess trend.

Outcome and Follow-up

Patient remained asymptomatic during initial follow-up period. Medical team emphasized the importance of not over-investigating normal physiological variations while maintaining appropriate vigilance for clinically significant changes. Family education provided regarding normal hemoglobin fluctuations and when to seek medical attention.