Psychiatric Inpatient Discharge Summary

Date Of Admission

Date of admission: 02/05/2026

Date Of Discharge

Date of discharge: 14/05/2026

Identification

M.T. is a 34-year-old single male with a BSc in Computer Science, currently on short-term disability from his role as a software developer. He has no children and has lived alone in a rented apartment in Toronto for the past 18 months, having previously lived with his parents in Mississauga.

History Of Presenting Illness

M.T. presented to the ED via EMS on 02/05/2026 following a wellness check requested by his mother. Approximately three weeks prior to admission (mid-April 2026), following a high-stress project deadline at work, he stopped taking his maintenance psychiatric medications. Over the subsequent two weeks, his sleep decreased to 2 hours per night, and he developed grandiose and persecutory delusions, believing he had discovered a flaw in the global banking algorithm and that intelligence agencies were surveilling his apartment. On 30/04/2026, his mother noted rapid, pressured speech and erratic spending totaling $12,000 on electronics. On the morning of 02/05/2026, neighbours called building security after he was found in the hallway dismantling smoke detectors to look for hidden cameras. Upon arrival to the ED, he was agitated, pacing, and irritable. I assessed him and admitted him involuntarily under Form 1 of the Mental Health Act with an admission diagnosis of Bipolar I Disorder, current episode manic, severe, with psychotic features. The initial management plan included close observation on the PICU, restarting lithium carbonate, initiating olanzapine for acute agitation and psychosis, and ordering baseline bloodwork and an ECG.

Past Psychiatric History

1. Bipolar I Disorder, diagnosed in 2019. He has no history of suicide attempts, self-harm, or physical assault. Prior medication trials include: aripiprazole (Abilify) 15 mg PO daily for 4 months in 2019, which was minimally effective for mania and discontinued due to severe akathisia; divalproex sodium (Epival) 1,000 mg PO QHS for 1 year (2019–2020), which stabilized his mood but was discontinued due to a 15 kg weight gain and sedation; and lithium carbonate 900 mg PO QHS from 2021 until April 2026, which provided good mood stabilization with mild hand tremor. Significant outpatient visits include: 1) 12/11/2025 – routine follow-up with outpatient psychiatrist Dr. R. Patel for medication renewal (euthymic); 2) 10/02/2026 – follow-up with Dr. R. Patel noting mild work-related insomnia.

(Past Psychiatric Admissions)

a. 14/06/2019 to 28/06/2019 (14 days), under the care of Dr. S. Vance at CAMH. Admission diagnosis was first-episode mania with psychotic features. He was stabilized and discharged on divalproex sodium and risperidone with follow-up in the first-episode psychosis clinic.

Medical History

1. Primary hypothyroidism (diagnosed 2022), managed with daily levothyroxine.
2. Appendectomy (18/08/2014), uncomplicated laparoscopic procedure.

Medications On Admission

1. Lithium carbonate 900 mg PO QHS (patient had not been taking for 3 weeks prior to admission)
2. Levothyroxine (Synthroid) 75 mcg PO daily (patient had not been taking for 1 week prior to admission)

Investigations

• CBC (02/05/2026): WBC 8.4 x 10^9/L, Hb 148 g/L, Plt 245 x 10^9/L
• Electrolytes & Creatinine (02/05/2026): Na 141 mmol/L, K 4.1 mmol/L, Cr 82 umol/L, eGFR 98 mL/min
• Serum Lithium Level (02/05/2026): < 0.1 mmol/L
• Serum Lithium Level (09/05/2026): 0.8 mmol/L
• TSH (02/05/2026): 6.8 mIU/L
• Urine Toxicology Screen (02/05/2026): Positive for cannabinoids; negative for amphetamines, cocaine, opiates, and benzodiazepines
• ECG (02/05/2026): Normal sinus rhythm, HR 92 bpm, QTc 418 ms

Mental Status Examination On Admission

• Appearance: Dishevelled, wearing mismatched layered clothing, unshaven, fair hygiene.
• Behaviour: Psychomotor agitation, pacing the interview room, intrusive, poor eye contact.
• Speech: Pressured, loud volume, rapid rate, difficult to interrupt.
• Mood: "Fantastic, never been clearer."
• Affect: Euphoric, labile, quickly shifting to irritable when questioned about medications, congruent with manic state.
• Thoughts: Flight of ideas, tangential. Content notable for grandiose delusions (believing he controls banking encryption) and persecutory delusions (surveillance by intelligence agencies). Denies SI/HI.
• Perceptions: Denies AVH; no evidence of responding to internal stimuli.
• Cognition: Alert, oriented to person and place, disoriented to exact date. Attention and concentration impaired due to distractibility.
• Insight: Absent; denies having a mental illness or needing hospitalization.
• Judgment: Severely impaired, evidenced by medication non-adherence, reckless spending, and destruction of property.

Course In Hospital

The following issues were addressed during the hospital stay

Acute Mania with Psychotic Features: On admission to the PICU, M.T. was restarted on lithium carbonate 600 mg PO QHS, alongside olanzapine (Zyprexa) 10 mg PO QHS and lorazepam (Ativan) 1 mg to 2 mg PO/IM q4h PRN for severe agitation. He required two doses of PO lorazepam during the first 48 hours. By 05/05/2026, his sleep improved to 6 hours per night, and he was transferred to the general inpatient ward. Lithium carbonate was titrated to 900 mg PO QHS on 05/05/2026; a trough level on 09/05/2026 was therapeutic at 0.8 mmol/L. His pressured speech, irritability, and grandiose beliefs gradually resolved over the second week. By 11/05/2026, he recognized that his paranoid beliefs were symptoms of his relapse. He tolerated the medications well without extrapyramidal symptoms.

Hypothyroidism: Baseline bloodwork on 02/05/2026 revealed an elevated TSH of 6.8 mIU/L secondary to recent non-adherence in the community. Levothyroxine 75 mcg PO daily was resumed on 03/05/2026. He remained clinically euthyroid throughout the admission with no physical symptoms of hypothyroidism.

Financial and Occupational Stressors: Due to reckless spending prior to admission and his ongoing absence from work, a social work referral was made on 06/05/2026. The inpatient social worker assisted M.T. in contacting his bank to freeze credit cards, arrange returns for unopened electronics, and complete medical documentation to extend his short-term disability leave through his employer.

Discharge Plan

The following issues were addressed during the hospital stay

Acute Mania with Psychotic Features: M.T. will continue taking lithium carbonate 900 mg PO QHS and olanzapine 10 mg PO QHS. A 14-day supply with one refill was faxed to his community pharmacy. He has an appointment scheduled with his outpatient psychiatrist, Dr. R. Patel, on 21/05/2026 at 14:00 for ongoing medication management and eventual tapering of olanzapine. He was educated on early warning signs of relapse (decreased sleep, racing thoughts) and instructed to return to the nearest ED if symptoms recur.

Hypothyroidism: Continue levothyroxine 75 mcg PO daily. He will follow up with his family physician, Dr. A. Singh, in 6 weeks for a repeat TSH level.

Financial and Occupational Stressors: M.T. will remain off work on short-term disability for the next 4 weeks, to be reassessed by Dr. R. Patel regarding a graduated return to work. His mother will temporarily assist with monitoring his bank statements.

Medications On Discharge

1. Lithium carbonate 900 mg PO QHS
2. Olanzapine (Zyprexa) 10 mg PO QHS
3. Levothyroxine (Synthroid) 75 mcg PO daily

Mental Status Examination On Discharge

• Appearance: Well-groomed, casually dressed in clean clothes, good hygiene.
• Behaviour: Calm, cooperative, pleasant, normal psychomotor activity, good eye contact.
• Speech: Normal rate, rhythm, and volume; spontaneous.
• Mood: "Balanced, feeling back to normal."
• Affect: Euthymic, stable, full range, mood-congruent.
• Thoughts: Linear, logical, and goal-directed. No grandiose or persecutory delusions. Denies SI/HI.
• Perceptions: Denies hallucinations in any modality.
• Cognition: Alert and oriented x3. Attention and concentration intact.
• Insight: Good; acknowledges diagnosis of Bipolar I Disorder and the direct link between stopping lithium and his manic relapse.
• Judgment: Intact; agreeable to outpatient follow-up, medication adherence, and financial safeguards.

Diagnosis

Primary Diagnosis: Bipolar I Disorder, current episode manic, severe, with psychotic features (supported by history of past mania, 2-week presentation of decreased need for sleep, pressured speech, flight of ideas, reckless spending, psychomotor agitation, and grandiose/persecutory delusions following lithium discontinuation).

Secondary Diagnoses: History of Primary Hypothyroidism.

“It was a pleasure to participate in this patient’s care. Please contact me with any questions.”

Sincerely,

Dr. E. Vance, MD, FRCPC Staff Psychiatrist