Chief complaint: “I have been experiencing difficulty sleeping for approximately

Chief complaint: “I have been experiencing difficulty sleeping for approximately a week.”
History of Present Illness: The patient, a 17-year-old female with a history of depression and anxiety, visited the clinic for a follow-up appointment accompanied by her mother. She reports experiencing poor sleep quality since she began taking Buspar 7.5 mg for her anxiety. The patient expressed feeling anxious, which has led to difficulty sleeping for more than three hours at night. She attributes these sleep disturbances to the initiation of Buspar treatment.
Mental Status Examination: The patient is oriented in all four spheres (person, place, time, and situation). She appears guarded, with a flat affect and withdrawn demeanor. The patient exhibits signs of anxiety and restlessness but otherwise appears to be her stated age and well-groomed. She denies current suicidal ideation. The patient demonstrates good insight into her problems and denies experiencing auditory verbal hallucinations.
Diagnosis: Based on the DSM-5 criteria, the patient is diagnosed with Insomnia Disorder (780.52, G47.00), Major Depressive Disorder (296.23, F32.2), and Generalized Anxiety Disorder (GAD) (300.02).
Plan: The patient will continue with psychotherapy, and the use of Buspar 7.5 mg will be discontinued. Instead, Seroquel XR 100 mg will be initiated, to be taken daily at bedtime, to address the patient’s mood and sleep difficulties. The patient is educated about potential medication side effects and the importance of medication adherence and treatment compliance. She is receptive to the provided information and willing to comply with the treatment plan. A follow-up appointment is scheduled in four weeks.