Skin appears pallored What is the best next step in the management of this patient?

A 65-year-old man presents with weakness and fatigue of 3 months’ duration. He states that he is usually very active, but as of late, he has been unable to participate in his normal activities. PMH: Coronary artery disease s/p 2 drug eluding stents (DES) 5 years ago Meds: Metoprolol, aspirin ROS: • Less frequent bowel movements, straining to push, and pencil-like stools • No abdominal tenderness to palpation SH: • Refuses screening colonoscopy • Refuses pneumonia and zoster vaccine FH: Father had colon cancer at 55 years of age Physical Exam: • Patient’s shirt appears too large • 20-lb weight loss since last visit 1 year prior • Pale conjunctiva • Skin appears pallored What is the best next step in the management of this patient?

a. Complete blood count (CBC)
b. Stool occult blood
c. Iron studies
d. Basic metabolic profile
e. Colonoscopy
f. All of the above

Answer f. All of the above
This patient is presenting with signs and symptoms of anemia, and given his age and risk factors most likely has colon adenocarcinoma. The first step is to establish the patient’s cause of fatigue by checking his CBC, iron studies, and kidney function. This should be combined with a stool occult blood test and eventually a colonoscopy if possible. If the patient had presented with melena, an upper endoscopy would have been considered, but given the change in bowel habits and stool caliber, it is likely a left-sided malignancy.
Hematochezia is more often caused by rectosigmoid than right-sided colon cancer.