ICD Coding — DS-IPD-2026-0481

Kavita Sharma · Discharge: 20 Jun 2026 · Dr. Prakash Iyer

Discharge Summary Excerpt

Presenting Complaint: High-grade fever, productive cough, SOB for 4 days.

Diagnosis: Community-Acquired Pneumonia (right lower lobe consolidation on CXR), Hypertension.

Procedures: Sputum culture + sensitivity, CXR, HRCT Chest.

Treatment: Inj. Ceftriaxone + Azithromycin, Inj. Hydrocortisone for severe component, O₂ therapy, BIPAP support ×48h.

Outcome: Improved, discharged on oral antibiotics. Follow-up in 2 weeks.

Assigned ICD-10 Codes

J18.9Pneumonia, unspecified organism
Principal Diagnosis

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