Colon and rectal cancer is the third most common cancer accounting for 1.93 million new cases in the year 2020. It is the second most common cause of cancer deaths in recent years. Newest guidelines suggest screening for colorectal cancer starting at the age of 45 for average-risk individuals of 40 years old or 10 years prior to youngest affected first-degree relative under the age of 60 or two or more first-degree relatives at any age with colorectal cancer or advanced polyp. This case is an example of a health-literate patient who missed warning signs suggestive of colorectal cancer secondary to initiation of Adderall and likely missed diagnoses in a deceased first-degree family member.

      42 year old male patient who works as a paramedic and a firefighter with past medical history of hypertension, depression, ADHD, anemia, gallstone pancreatitis, Hodgkin’s lymphoma (in remission for 12 years), and status post gastric bypass 9 years ago came to the hospital for evaluation of right upper quadrant abdominal pain for the past 3 days not alleviated by ibuprofen. Patient denied nausea, vomiting, black/tarry or bright red blood in his stool. Patient endorsed good oral intake. He had no family history of colorectal cancer but mother passed away in her 40s from a bowel obstruction and subsequent perforation and sepsis of unknown etiology (no autopsy was performed). Patient has never had a colonoscopy in the past. He was started on Adderall a few months ago for ADHD and endorsed mildly decreased appetite during the day and a 20-30 pound weight loss since initiation of the medication, which the patient attributed to the initiation of medication. Patient had a 10-pack year smoking history, quit 14 years ago, and now intermittently smokes cigars. On admission, he was found to have hemoglobin of 11, abdominal CT showed exophytic mass in the transverse colon and a lesion in the right hepatic lobe. Patient underwent a colonoscopy that revealed a mass in the distal ascending colon (Figure 1 & 2). Biopsies were taken with cold forceps for histology, which were positive for adenocarcinoma. He subsequently underwent right colectomy with primary anastomosis. Patient was then started on a modified FOLFOX6 chemotherapy regimen.

      Weight loss is always a red flag pointing practitioners towards the possibility of a malignancy. This patient's unfortunate coincidence of initiation of Adderall with likely weight loss from malignancy delayed his presentation. His mother's passing at a young age with no autopsy done at that time prevented the possibility of the patient initiating screening colonoscopies at an earlier age if a colorectal cancer was the source of the bowel obstruction. This combination of factors delayed the diagnosis of colorectal adenocarcinoma in a very health-literate patient.