Patient presents with symptoms suggestive of congestive heart failure (CHF) secondary to hypertension.  The patient reports dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, and lower extremity edema.  Physical examination reveals elevated blood pressure (current reading documented), jugular venous distension, and bibasilar crackles upon auscultation.  The patient's medical history includes long-standing hypertension, which is poorly controlled despite current medication regimen (list current medications).  Electrocardiogram (ECG) shows (ECG findings, e.g., left ventricular hypertrophy, sinus rhythm).  Chest X-ray reveals cardiomegaly and pulmonary congestion.  Echocardiogram is scheduled to assess left ventricular ejection fraction (LVEF) and overall cardiac function.  Diagnosis of hypertensive heart failure is made based on clinical presentation, physical exam findings, and preliminary diagnostic tests.  Treatment plan includes optimization of hypertension management with (mention medication adjustments, e.g., addition of ACE inhibitor, beta-blocker, or diuretic), patient education on lifestyle modifications (sodium restriction, fluid restriction, weight management), and close monitoring of symptoms.  Patient advised to follow up for repeat echocardiogram and reassessment of CHF symptoms.  Differential diagnosis includes other causes of dyspnea and edema such as chronic obstructive pulmonary disease (COPD) and renal insufficiency, which are being considered and investigated. Medical coding will include ICD-10 codes for hypertensive heart disease with heart failure (I11.0) and related conditions as indicated by further diagnostic workup.  This documentation supports medical billing for evaluation and management (E/M) services related to the diagnosis and management of congestive heart failure and hypertension.