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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

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