Unable to obtain reliable PH, substance abuse hx at this time, vague ,

circumstantial, superficially cooperative , somewhat internally preoccupied ,

illogical with loose thought process. Presence of ah could not be r/o at this
point although pt denied presence of any perceptual disturbances. Denied
suicidal, homicidal ideation s, intention , or plan. Clear mentation., Good
impulse control
Pt declined with psychotropics , prn meds ordered for severe agitation; side
effect explained , monitor Ms and reevaluate