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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