A 53-Year-Old Man Comes to the Office Due to Persistent

question 132

Multiple Choice

A 53-year-old man comes to the office due to persistent fatigue.  The patient started a therapeutic dose of fluoxetine 2 months ago after being diagnosed with major depressive disorder.  He says, "Since I last saw you, I still feel like I'm dragging pretty much every day and have to force myself to go to work in the mornings.  I haven't even wanted to have sex with my wife.  That's been going on for almost a month, and it's really bothering me."  The patient works as a high school English teacher and notes, "It takes me so long to grade my students' essays because I am so easily distracted."  Medical history includes hypertension treated with enalapril.  He had a 4-kg (9-lb) weight gain over the past 2 months.  Blood pressure is 130/84 mm Hg and pulse is 76/min.  Physical examination shows no abnormalities.  The patient appears depressed and speaks softly throughout the interview.  Which of the following is the most appropriate next step in pharmacotherapy?

• A)Continue fluoxetine and add aripiprazole
• B)Continue fluoxetine and add methylphenidate
• C)Discontinue fluoxetine and begin bupropion
• D)Discontinue fluoxetine and begin venlafaxine
• E)Increase dosage of fluoxetine
• F)Increase dosage of fluoxetine and add sildenafil

---

Definitions:

Keto-enol Tautomerization

Keto-enol tautomerization is a chemical equilibrium between a ketone (or aldehyde) and an enol (an alcohol directly bonded to a carbon-carbon double bond), where hydrogen atoms and double bonds are redistributed.

6-phosphate Ester

Refers to a compound containing a phosphate group attached to the sixth carbon of a sugar or organic molecule, commonly involved in energy transfer and signaling pathways.

Sucrose

A sweet substance made from glucose and fructose, familiarly referred to as the sugar found in sugar bowls.

Monosaccharides

Simple sugars that are the most basic units of carbohydrates, with a single polyhydroxy aldehyde or ketone unit.