Upping the Ritalin

“So basically, what we have here is a medicine adjustment.”

The attending physician regarded his intern, considered his words, took a slow, barely perceptible breath, and commenced. “Please, just run the facts of the case by me again, would you?” he asked.

The intern nodded, composed himself, and began. “This woman comes today for an adjustment of her son’s Ritalin dose, if it is necessary. He has the diagnosis of attention deficit hyperactivity disorder and has been on Ritalin for the past school year. It is not controlling his symptoms and the primary care doctor has referred him here for dosage adjustment. Except for the hyperactivity he is in good health. Had an uneventful pregnancy, birth weight of seven pounds ten ounces; three days in the nursery, no recognized allergies, no other medicines. He has had the usual childhood illnesses and a hernia repair. No history of seizure, cerebral palsy or migraine and no cancer, diabetes, or heart disease in the family. Physical and neurologic examinations are normal. Because the current dose is only five milligrams per day and this is a small dose, I recommend upping the dose to five milligrams in the morning and an additional five at noon. We can see the patient back in three months to see how he is doing. I do not recommend an EEG or a neuroimaging study for this patient at this time.”

He paused, confident he had delivered an excellent presentation. Thus, the first question took him a bit by surprise.

“How do you know this patient has attention deficit hyperactivity disorder?”

“The mother provided the history,” he answered.

“She told you that was the correct diagnosis?”

“Yes, she told me that was the diagnosis,” he replied, thinking that if the attendings would pay attention he wouldn’t have to repeat …