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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 June 2009 due to substance dependence. Upon admission,
comprehensive psychiatric and somatic assessment confirmed polysubstance dependence
syndrome. Urine toxicology screening was positive for opioids, cannabis, and benzodiazepines.
Liver function tests revealed mild hepatic impairment. During his inpatient stay,
the patient underwent structured detoxification with monitored pharmacological substitution
and symptomatic withdrawal management. Psychological assessment and motivational counselling
sessions were conducted. The patient was stabilised without major complications and
discharged on 8th July 2009 in a clinically stable condition. We strongly recommend
continued outpatient addiction counselling and regular follow-up appointments. Referral
to a community drug treatment programme has been arranged. Please monitor liver function
and mental health status closely. Yours sincerely, Dr. [Treating Physician]
Diagnosis at Discharge
| Mental and behavioural disorders due to multiple drug use – dependence syndrome | 08-Jul-2009 | active |
Significant procedures
| Discharge planning and social support coordination | 05-Jul-2009 | - |