Medical History and Records

I was able to get a copy of Jakob's medical records today while at the doctors. It was interesting to read the history of his visits. I haven't taken him in every time he has a fever. And some of the months we were living in SL or SG. But it is still enough to show us that he does have a history of a fever month after month.

From the looks of the records March through June are his sickest months. But like I said I don't have all the details of the other months, just our memory. I didn't really remember how often ear and throat pain was a leading symptom along with the fever. I think that's why I took him to the doctor (concerned about infection). But it was mentioned that the strep tests were all negative and the ear infections were just the conclusion to what the ear looks like (inflamed.) He was prescribed antibiotics almost every time.

Our Family Doctor said that he will do some research about Periodic Fever Syndrome and we will meet with him again on Friday.

MEDICAL HISTORY
January 2006 - June 2008(Minus August-November 2006 and July-December 2007)

March 20, 2006: Mom says Jakob has had a cold for a week or so, wanted to check his ears for infection and weight because he seems to gain weight slowly.
Diagnosis: Upper Respiratory Infection. 5th percentile in height and 10th percentile in weight, but mother is only 5 feet tall. Height and weight match up pretty well.

May 24, 2006: Complaining of a fever and fussiness for the past 2-3 days and also pulling at his ears. Some nasal congestion. Fever 102.1. Right ear Erythematous (Redness of the skin caused by dilatation and congestion of the capillaries, often a sign of inflammation or infection.) and bulging. Left ear normal.
Diagnosis: Right Otitis Media (Inflammation of the ear, The middle, often muscular layer of the wall of a blood vessel) Prescribed Augmentin.

December 20, 2006: Sore throat, pulling at ears, runny nose, fever 101.0 for past couple of days. Giving Tylonal with no improvement.
At Visit: Fever 99.9, weight 25 pnds, slightly pale in color, slightly dehydrated, no respiratory distress. Ear drums are slightly retracted, otherwise canals are clear. Throat is bright red with tonsil enlargement. white patches in the back of the pharynx. Nasal has clear thin discharge. No swollen lymph nodes. Heart rate slightly increased to 114. Rapid Strep Test (negative)
Diagnosis: Pharyngitis (inflammation of the pharynx) and Tonsillitis (inflammation of the tonsils) Prescribed Amoxicillin.

January 12, 2007: Jakob has just gotten over a recent upper respiratory tract infection. However, mom noticed that since then he has looked paler then usual and has not had as much energy. Wondering about Anemia.
Diagnosis: Possible Anemia. Check hemoglobin and hematocrit.
Lab Results: Hemocrit results 36.7, units %, Reference 30.0- Interval 42.0
Hemoglobin results 12.4, units g/dL, Reference 10.0-Interval 14.0
No Anemia

April 19, 2007: Mother concerned about possible Reflux again. Past couple of days Jakob has had a dry cough at nighttime, with small amount of reflux in his mouth and odor smells acidy.
Vitals: weight 27 pnds, Pulse 110, Temperature is 97.5, Ears fine, mild erythema in both pharynges, Nasal Mucosa: Slightly inflamed with thick discharge. Neck is supple without adenopathy.
Diagnosis: Allergic Rhinitis (Inflammation of the nasal mucous membranes), Gastroesophageal Reflux
Prescribed: Zyrtec and Zantac

May 7, 2007: Complains of fever for three to four days, increased fussiness, and not sleeping very good last night.
At visit: Weight 27 pnds., Temp. 98.6
Left ear drum was normal. The right one was very erythmatous and bulging and dull-appearing. Nose was moderately congested.
Diagnosis: Otis Media. Prescribed Augmentin

June 14, 2007: Sore throat and fever for past three days, threw up a few days ago and not since.
At Visit: Temp. 97.5, weight 26.5 pnds., Eardrums slightly retracted with middle ear effusion. No infection is noted. Ear canals are clear. Throat is bright red with no red patches or exudates noted. Tonsils are slightly enlarged, nasal mucosa is inflamed with clear thin discharge. Neck is supple without adenopathy.
Diagnosis: Upper respiratory infection, pharyngitis, tonsillitis
Prescribed: Augmentin.

January 30, 2008: High fever over the past couple of days and pulling on both ears. Complains of sore throat and congestion, not eating as well.
At Visit: 29 pnds., Temp. 98.1, right eardrum is retracted with some middle ear effusion. Left eardrum is red and bulging and the canal is slightly red. Throat: mild erythema in the back of the pharynx. No exudate or swelling noted. Nasal mucosa with clear thick discharge with slight inflammation of mucosa. Neck: Supple, no adenopathy.
Diagnosis: Left otitis media, Upper respiratory infection, viral syndrome.
Prescribed: Amoxicillin

WOW! After reading and writing this history all down I can see some things a lot more clearly. The first thing I note is that all of Jakob's symptoms have been the same. Part of the reason they are always the same at the doctors is because I usually only take Jakob to the doctor when I am concerned that there might be an infection involved. There have also been times that I have asked the nurses/doctors to look at Jakob's ears during my OB appointments instead of making an official appointment. I don't think they make records of these incidents and usually the ear and temp would be okay even though he was sick earlier, or maybe I declined the antibiotic prescription. This year I've really tried to minimize the antibiotics Jakob uses. Augmentin gives him a Horrible diaper rash.

I also noted that there was a lot of inflammation with little clear sign of infection (in my opinion.)
My thought is that Jakob may have Periodic Fever Syndrome or he really needs his tonsils out and tubes put in his ears.

Another thing is that the doctor never noticed swollen lymph nodes. But as far as I can clearly remember (within this year 08) I have noticed swollen lymph nodes on his neck. Sometime around February or March I even tried to make a lotion with several antibacterial herbs to rub on his neck and feet.

Jakob started Preschool in January 08. He missed at least one week of school every month (January-May.) I obviously didn't make any official doctors appointments. But those were the last few months of my pregnancy with Caleb so I'm sure we consulted with the doctor a bit. I remember him distinctly coming down with sudden high fevers, vomiting, and cold symptoms. I just don't remember the dates except that his May fever was around the 16th (the last week of his preschool.) Within the last few months his right knee has started to ache during the fever episodes.