How to write a discharge letter

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The question you should ask is, 'if I got this as a letter would it give me enough information to know what happened, what to do next, what could I expect and what should my response be if something goes wrong'. NB. you are on a specialist unit providing guidance to a non-specialist

Yet again a familiar case.......

17 yo unemployed male living with his family. Several months of social withdrawal, unkemptness and poor hygiene. Heavy tobacco smoker and regular cannabis user. Previous experimentation with amphetamines and LSD.

Experiences paranoid beliefs that he is under surveillance by bikie gangs, phone is tapped and that listening devices are in his house. Also experiences auditory hallucination of persecutory nature and more recently, command hallucinations to commit suicide.

Examination revealed casually dressed male with evidence of poor self-care. He was orientated to time, place and person but appeared anxious, fearful and agitated. Conversation was often tangential and preoccupied by themes of being killed by bikie gangs. He demonstrated impairment in short term memory that may have been influenced by his thought disorder. He showed poor insight and judgment and was resistive to admission and treatment.

The patient was detained to the locked ward of a mental health unit whereupon he became increasingly agitated and paranoid and attempted to abscond. This required temporary physical restraint. Eventually spontaneously settles without chemical sedation. Commenced on risperidone and agitation settles overnight but paranoia persists. Later in the week, behaviour settles and patient is transferred to open ward. Patient begins complaining of muscle stiffness and pain, stiff gait and hand tremor which is temporarily relieved with benztropine but followed by blurred vision and dry mouth. Persistent stiffness results in medication changed to olanzapine responding with gait improvement a few days later. The patient continued with individual supportive counseling and family meetings were organised for education.

Outpatient group sessions were offered and various community support groups suggested. Symptoms resolved by the end of week 3 and the patient was discharged.

After several weeks of treatment, the patient complained of excessive appetite and weight gain but remained amotivated, socially withdrawn and poorly communicative. Exercise was recommended and heeded with temporary weight improvement. Erectile dysfunction became problematic later and psychiatric symptoms worsened again with paranoia and poor sleep. Compliance to exercise and psychotherapy was therefore affected. The patient was switched to clozapine with regular blood counts arranged. The patient experienced sleepiness and increased salivation but after several weeks of treatment, paranoia settles and patient begins to develop insight into his illness. Participating in living skills and vocational rehabilitation allowed the patient to enter a trade apprenticeship. Sexual function improved but weight gain remains an issue (associated with mild glucose intolerance) which required dietetics input. Several months later, the patient re-experiences mild paranoid ideation in the context of missing his medication and experimenting with amphetamines. This quickly resolves with resumption of medication and further education is given. During his studies experiences a failed relationship with a woman but despite this coped well. The patient remains compliant to medication and follow-up and advised that treatment will be life-long.

Letter to GP or private psychiatrist at time of discharge......

Dear Dr. Allthings,

Thank you for continuing the care of Jared Callahan

He is a 17 year old male admitted to the psychiatric ward for three weeks for the assessment and treatment of new-onset paranoid psychosis. He has a history of cannabis use but it was felt that his likely problem was a first presentation of acute schizophrenia.

Initially he was quite agitated and required admission to the closed ward for several days. He later settled on medication. Due to an inability to tolerate risperidone from extrapyramidal side effects, he was finally managed with olanzapine.

When he was first seen he demonstrated intense paranoid beliefs that he was under surveillance by bikie gangs, his phone was tapped and that listening devices were in his house. He also experienced auditory hallucination of a persecutory nature and command hallucinations to commit suicide. Mental state exam revealed a young man with evidence of poor self-care. He was orientated to time, place and person but appeared anxious, fearful and agitated. Conversation was often tangential and preoccupied by themes of being killed by bikie gangs. He demonstrated impairment in short term memory that may have been influenced by his thought disorder. He showed poor insight and judgment and was resistive to admission and treatment. All of these symptoms eventually settled with treatment.

The patient continued to participate with individual counseling and several meetings with the family occurred through our social worker. After 3 weeks he was discharged into the care of his family. He has an appointment for outpatient group sessions and been given contact with community groups. Can you monitor him for compliance to his medication and address any problems resulting from them? We have warned him of the potential weight gain and of sexual dysfunction with olanzapine. Questions about any issues can be directed to the consultant psychiatrist, Dr. S. Freud.

Sincere Regards,

Dr. D. Lee Gent (Psychiatry RMO)

cc. Psychologist - Dr. Pavlov

cc. Community Psychiatric Team (Upper Kumbukta West)