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Hospital Discharge Report
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Synthesis
Substance dependence, treated and stabilised
Hospital course note
Dear colleague, thank you for referring this 46-year-old female patient, admitted
on 02.01.2020 due to substance dependence disorder. Upon admission, a comprehensive
psychiatric and somatic assessment was performed, confirming dependence on multiple
substances including opioids and benzodiazepines. Withdrawal symptoms were present
and required immediate clinical management. During her inpatient stay, a structured
detoxification protocol was initiated, including pharmacological withdrawal treatment
and close monitoring of vital signs and neurological status. Motivational counselling
sessions were conducted, and a psychosocial needs assessment was completed. The patient
stabilised well without major complications. At discharge on 05.01.2020, she was referred
to an outpatient addiction support programme and her primary care follow-up was arranged.
We recommend continued monitoring and engagement with community addiction services.
Please do not hesitate to contact us should further information be required.
Diagnosis at Discharge
| Mental and behavioural disorders due to multiple drug use – dependence syndrome | 05-Jan-2020 | active |
Significant procedures
| Referral to outpatient addiction programme | 05-Jan-2020 | - |