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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 34-year-old
male patient, admitted on 15/10/2008 due to substance dependence disorder. Upon admission,
a comprehensive psychiatric and somatic assessment was performed, including structured
diagnostic interviews, urine toxicology screening, and laboratory investigations confirming
polysubstance dependence. The patient underwent medically supervised detoxification
with pharmacological support to manage withdrawal symptoms safely. During the inpatient
stay, he participated in individual psychotherapy sessions and psychoeducational group
therapy addressing substance use behaviours and relapse prevention strategies. Motivational
interviewing techniques were employed to strengthen treatment engagement. The patient
was stabilised without significant complications. At discharge, he is abstinent and
motivated for continued outpatient treatment. We strongly recommend referral to an
outpatient addiction programme and close follow-up. Prescription details and further
recommendations are enclosed.
Diagnosis at Discharge
| Mental and behavioural disorders due to multiple drug use – dependence syndrome | 09-Nov-2008 | active |
Significant procedures
| Relapse prevention counselling | 05-Nov-2008 | - |