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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 75-year-old
male patient admitted on 25/11/2015 due to substance dependence. Upon admission, a
comprehensive psychiatric and medical assessment confirmed multiple substance dependence
syndrome (ICD-10: F19.2), with evidence of polysubstance use. Withdrawal monitoring
was initiated immediately alongside structured detoxification. During his inpatient
stay, the patient underwent motivational counselling, individual psychotherapy sessions,
and pharmacological support to manage withdrawal symptoms and cravings. Medical comorbidities
were reviewed and managed accordingly. By the time of discharge on 06/12/2015, the
patient was clinically stabilised, with no active withdrawal symptoms. Referral to
outpatient addiction services and a community support programme has been arranged.
Continued follow-up with your practice is strongly recommended to monitor his progress
and maintain abstinence. Please do not hesitate to contact me for further information.
Diagnosis at Discharge
| Mental and behavioural disorders due to multiple drug use – dependence syndrome | 06-Dec-2015 | active |
Significant procedures
| Discharge planning and referral to outpatient addiction services | 05-Dec-2015 | - |