Patient presents with a history of traumatic brain injury (TBI).  The initial injury occurred on [Date of Injury] and was characterized as [Severity of TBI: mild, moderate, severe] based on [Glasgow Coma Scale score at time of injury, duration of loss of consciousness, post-traumatic amnesia duration].  The mechanism of injury was [Mechanism of injury, e.g., motor vehicle accident, fall, sports injury, blast injury].  Current symptoms include [List current symptoms, e.g., headaches, dizziness, cognitive impairment, memory problems, difficulty concentrating, emotional lability, sleep disturbances, sensory changes].  Neurological examination reveals [Specific neurological findings, e.g., normal cranial nerves, intact motor strength, mild gait instability].  Patient reports a history of [Prior treatment for TBI, e.g., hospitalization, rehabilitation, medications].  Current medications include [List current medications].  Assessment suggests post-concussion syndrome related to the prior TBI.  Plan includes [Treatment plan, e.g., referral to neuropsychology for cognitive evaluation, occupational therapy for functional assessment, medication management for symptom control, patient education regarding TBI management].  Differential diagnoses considered include [List differential diagnoses, e.g., migraine, anxiety disorder, depression].  ICD-10 code: S06.9 (Unspecified traumatic brain injury).  Further evaluation and management will be based on patient response to treatment and ongoing symptom presentation.  Prognosis is dependent on the severity of the initial injury and the presence of persistent symptoms. Continued monitoring for neurological deficits is warranted.