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Hospital Discharge Report
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Synthesis
Substance dependence, treated and stabilised
Hospital course note
Dear colleague, I am writing to inform you regarding the discharge of your 35-year-old
male patient, admitted on 10th December 2016 due to substance dependence. Upon admission,
comprehensive psychiatric and somatic assessment confirmed multiple drug dependence
syndrome (ICD-10: F19.2), including polysubstance use involving opioids, benzodiazepines,
and cannabis. Urine toxicology screening was positive for multiple substances. During
inpatient stay, medically supervised detoxification was initiated, including symptomatic
pharmacological management of withdrawal symptoms. Motivational counselling sessions
and structured psychoeducation regarding substance misuse were provided. The patient
was stabilised without significant complications. At discharge, the patient is abstinent,
medically stable, and has been referred to an outpatient addiction counselling service.
Continuation of motivational therapy and regular follow-up is strongly recommended.
Please do not hesitate to contact me for further information.
Diagnosis at Discharge
| Mental and behavioural disorders due to multiple drug use – dependence syndrome | 26-Dec-2016 | active |
Significant procedures
| Discharge planning and addiction referral | 23-Dec-2016 | - |