Refer to hematology for a comprehensive bleeding workup, as new-onset bruising without prior history suggests an underlying coagulopathy requiring specialist evaluation.

Hematology referral may be appropriate if the workup reveals a primary bleeding disorder, but the drug interaction should be assessed first given the clinical context and temporal relationship to aspirin initiation.

Discontinue aspirin immediately, since it is the most recently added medication and the most likely single cause of the new bruising symptoms.

Unilaterally discontinuing a cardiologist-prescribed medication without coordination is inappropriate. The aspirin may be essential for cardiovascular risk reduction.

Assess for an SSRI-aspirin interaction, as SSRIs impair platelet aggregation and the combination produces additive bleeding risk requiring lab evaluation and care coordination.

SSRI-antiplatelet interactions are clinically significant and commonly tested. SSRIs deplete platelet serotonin, which is necessary for aggregation. Combined with aspirin, bleeding risk increases — particularly GI bleeding. Obtain a CBC with platelets to assess for thrombocytopenia, review for other anticoagulants or NSAIDs, and coordinate with the cardiologist regarding the risk-benefit of the combination. If bleeding risk is significant, consider switching to an antidepressant with less serotonergic platelet effect (e.g., bupropion, mirtazapine). The PMHNP should assess the clinical significance (severity and location of bruising, any GI symptoms) and coordinate with the cardiologist (aspirin may be essential post-cardiac event).

Reduce paroxetine to 20 mg to lower the serotonergic effect on platelets while maintaining partial anxiolytic benefit from the medication.

Dose reduction may partially reduce the effect but does not eliminate the pharmacodynamic interaction, and may compromise anxiety treatment without adequately addressing the bleeding risk.