I need 400 words to edit and proofread my 4 medical cases

Instructions

Edit and proofread

I have medical cases I need Expert in :

1. Editing for the cases. 

2. Proofreading. 

3. Writing Discussion part ( Zero plagiarism ). 

my teacher assigned me 4 cases and she would like to train us how to write case series 

I tried my best to write them but she sends me back 2 times saying need further review 

I don't know how to edit them 

My task is to report Down syndrome with atlantoaxial instability .. My teacher said that my writing is too much and I need to be more focused on the reporting. 

I am not expert on how to eliminate. Please eliminate it 

No specific number but needed to be focused 

she said it verbally 

she said is too long, and many information is not needed to write if you would report such cases.

.......................................................................................................................................................................................

Attachment 1:

Case 1 :

A 43 months old boy, diagnosed with Trisomy 21 at birth, known case of Hydronephrosis Grade 1 and small PDA with PFO. The patient was born via C section due to Breech Presentation.

 At the age of 50 days, the patient was brought to ER with compensated septic shock and necrotizing fasciitis of the nose by Pseudomonas Aerginosa. Plastic Surgery were consulted regarding an extraveasation injury found in the Right lower thigh, 2x3 cm with irregular sharp demarcated dark red edges. The patient was kept on daily dressing with Fucidine and Jelonet every 8 hours. Vancomycin, Meropenom, Amikacin, and Amphotricin B were given.

Oral and Maxillofacial Surgery were consulted regarding his necrotizing fasciitis of the nose. The patient was found to have supernumerary tooth which was extracted at bedside. Extraction of Mesiodens and soft tissue excision was also done with good bleeding control and under local anesthesia. The Specimen was sent for Histopathology lab which showed Pygenic Granuloma which has a 15% chance of recurrence. Since there is no signs of infection and the source was removed, no further intervention was needed.  

When the patient turned 36 months old, he presented to the ER with a history of Torticollis and decrease oral intake for two weeks. Further details were given stating that for the 8 months, the parents have been noticing repetitive falling down associated with Right upper limb weakness with deviation of the neck towards the left side and inability to turn to the right side. The patient had also difficulty in sitting or standing and he was laying in the bed all the time. There were no history of episodes of fever, abnormal moment, skin rashes, changes in the bowel habits, or changes in the urine. Examination showed at least 4 out of 5 power in all limbs which he can move with minimal resistance. Patient was kept on a C collar and CT scan was done which demonstrated a displaced fracture involving the Odontoid synchondrosis with anterior rotatory discplacment of C1. A compression of the spinal canal was also appreciated which needs further evaluation with MRI. An order for Cervical MRI under general anesthesia was done which showed Odontoid process commented displaced fracture, anterior rotatory displacement of C1, craniocervical junction ligamentous injury and narrowing along with underlying focal cervicomedullary junction myelomalacia with no acute traumatic brain injury. The patient was followed up by Neurosurgery and their plan was for surgical intervention to do Reduction and Internal Fixation of Cranicervical Junction. Oral feeding was started slowly after having Clinical Nutritious on bored which the patient started to tolerate slowly. 

After the surgery, the patient became hypoventilated and oxygen saturation started to decrease and the patient was intubated to prevent any permanent damage caused by hypoxia. After that, the patient was examined by the neurosurgery team and his power was 4/5 in the lower limbs but both of his upper limbs decrease to 2-3/5. Therefore, a CT scan for the brain and cervical spine was done and showed Normal looking brain with no compression of the spinal cord. The patient was kept conscious but sedated using Fontanel and Epinephrine to keep MAP above 65 mmhg. For further evaluation, MRI was ordered which showed no significant changes compare to his Pre- Op imaging. During his stay in the PICU, the patient was given 2 mg of Dexamethsone every 6 hours and Cefazoline. His GSC was 9/15. Daily labs for CBC, Electrolytes, ABG, and Coagulation Profile was taken. The patient started to develop a few spikes of fever and his WBC count was 16.30. Reparatory, Urine and Blood cultures were taken which were negative. However, Chest X ray showed a complete opacification in the right upper lobe therefore the patient was switched to Ceftazidim and Vancomycine. The PICU team started to taper down the Dexamethsone dose over one week until it was discontinued. When the sedation is low, the patient was able to breathe above the ventilation setting and the team decided to begin weaning off the sedation for the extubation. Patient was started on Physiotherapy to his limbs to prevent spasticity. The vitals of the patient were stable with a few episodes of bradycardia. His GSC started to improve reaching to 11/15. On the 8th day post-surgery, the wound was examined and it showed no signs of infection or active bleeding.

The patient was started on therapeutic Heparin as he was found to have the Right Common Iliac, External Iliac, the Common Femoral, and the Superficial Femoral Vein all thrombosised with no follow of blood detected. Haematology were consulted regarding the investigation of an underlining haematological disease. The patient was started on Enoxprain due to bilateral lower limb DVT. The patient is almost having quaderparesis and is on antibiotics for his chest infection. The patient was still spiking fever and not improving on the antibiotics and Viral Panel was sent which came back positive for HSV- 1. Patient was started on Acyclovir and Caspofungin while waiting for the fungal culture. Capsofungin was switched to Fluconzole after one day.  

 His X ray is showing worsen of the Pulmonary Edmore on the right side of the lung. The patient was started on Furosemide to decrease the pulmonary edema. He later started to develop generalized body edema which is managed with Furosemide.

The patient GSC went down to 10/15. His ability to move his right side was only limited to pain with power 2-3 which was higher in the lower limbs. On the left side, his power was 0/5 except in the thumb were it was 2/5.

The patient started to have a mild distended abdomen with a few episodes of fever and the primary team added Bactruim to his medications.

He is still intubated and on C collar as he cannot maintain his breathing. The patient was ventilated via HFOV ventilation mood on FIO2 60% and a saturation ranging between 87%- 88%. The team discussed the option of doing a Tracheostomy to the patient which was done.

An MRI was done with contrast showing Interval prominence of ventricle and peri cerebral space suggesting mild brain volume loss. It also showed abnormal signal and myelomalacia changes in the upper cervical cord.  

The patient still has episodes of on and off fever which settles down on it is own. ID team is following the patient and suggesting to keep the patient on the current medications for the course of the treatment which is 14 days. Haematology team have recommended to keep the patient on Enoxaprine and hold it 24 hours before any procedure. LMWH level should be done weekly and the sample should be taken 4 hours after the morning dose. Keep the Platelet count above 50,000, BUN and Creatinin level weekly, and do Doppler US three months after the treatment. Dental team is consulted as the injuring his lip by his teeth.  

The patient is in his baseline for his vitals. He is now on Miami J collar which is planned to be kept for 10 – 12 weeks. Later on, the patient developed left pneumothorax and a chest tube was inserted and kept unclamped to help in resolving it. Patient is on mechanical ventilation for training. The patient was scheduled for a cervical CT which showed improvement compare to the previous post-surgical findings. The patient had a GT insertion to help maintain his nutrition. The feeding rate is 135 ml every three hours.

Patient had multiple spikes of fever and a septic work up was done which showed positive growth of Staphylococcus Aurous and he is on Clindamycin. His current ventilation setting is SIMV PRVC PEEP 6 FIO2 25%. The patient was later found to have bilateral ankle clonus and Neurology team were involved. Their plan is to send for Liver Profile first and if the results are normal, start Baclofen 2.5 mg OD for one week then increase to 2.5 mg BID as long as the Liver Profile is normal.  

Currently, the process of weaning of the Oxygen is still on going. The patient is planned to have Revascularization for the persistent left common iliac, external iliac and common femoral vein thrombosis. His latest MRI showed, Post reduction of a displaced odontoid process fracture; with interval regression of retro odontoid anterior epidural haematoma, as described above." Unchanged upper cervical cord medullary abnormal signal and myelomalacic changes.  

Case 2:  

This is a 41 months old preschool age girl, know case of Down syndrome, and she has normal intracardiac anatomy and function. Her past medical history is significant for chronic constipation, and her past surgical history is unremarkable. She presented to the general pediatric clinic complaining of difficulties in grapping by her left hand and bearing her weight started gradually worsening with time until noted by the father when she started to have difficulties in crawl as well. Furthermore in the history, her mother started to notice involuntary abnormal movement of the foot. Jerky in nature, stops when hold 4 months ago. Her developmental history is in the gross motor she started to set at age of 12 months and used to pull to stand at age of 24 months and now she can only crawl for short distance, and she cannot pull herself up to stand anymore. In the fine motor she transfer objects from one hand to other hand at age of 12 months and she had the pincer grasp at age of 24 months and now she can hold objects on the right hand, but she cannot do so by the left hand. In the language she can say Mama and Dada at age of 24 months and now: she say few words like mama, dada, and her sibling's names. The social diameter she had the stranger anxiety at the age of 12months and now she can express her emotion. On examination, she looks well, active, smiling, not in pain, and her vital signs are within normal range. Her motor examination showed axial hypertonia and poor head control with normal muscle bulk and no fasciculation. Her cranial nerves examination is unremarkable. Her power examination showed that the power in the right arm and right is 4 out of 5, and the power in the left arm and left leg is 3 out of 5. Her reflexes examination showed the deep tendon reflex (DTR) in both brachialis tendons is 2+ and the deep tendon reflex (DTR) in both patellar tendons is 3+. Additionally, she has a sustained bilateral clonus which is more in the left leg. So the patient was referred and assessed by the neurology team, and she was admitted for further evaluation and investigation. First spinal X-ray was done and showed that preodontoid space is measuring 3 mm for CT scan if the concern is about osseous abnormalities, or MRI of the may concern is spinal cord. Then, a cervical Spine CT was done and showed that there is severe narrowing of the craniovertebral junction. There is shortening of the posterior arch of C1 vertebral body with posterior inclination of the odontoid process. The spinal canal at the same level measures 0.5 cm. There is anterior displacement of the os odontoideum noted. Then the brain and spine MRI was done and showed that the findings of severe narrowing of the craniocervical junction with associated myelomalacia. Then the patient underwent a Cranio-circumfusion under the care of neurosurgery team. Afterwards the postoperative cervical spine CT was done and showed that the postoperative changes with interval decompression of the upper cervical spinal canal and the alignment of the odontoid process is maintained. The patient was discharged on cervical collar in stable condition, with regular follow up with neurosurgery clinic. 

Case 3 :  

11 years old male known case of Down syndrome presneted one year ago to ER with history of neck pain and torticollics started after operation for cholecystectomy done before 3 weeks of this presentation. There was no history of trauma, seizure,fever or photophobia. Patient was in severe pain tilted his head to right side, he has tendereness upon touching.Upon examination power,tone and reflexes are intact.

In ER they ordered neck soft tissue X-ray and it showed straightening alignment of cervical spine and preserved vertebral body height and disc spaces no sclerotic or lytic lesion detected. Also they ordered cervical spine CT and it showed anterior subluxation of the right lateral mass of C1 in relation to C2 lateral mass as well the right occpital condyle. There was widening of atlanto-dental space with mild superior migration of the odentoid process, the reminder of cervical spine verterbra maintain normal alignment, mildly reserved cervical lordoisis with partial non fused left anterior C2 vertebral body. There was segmentation fusion anomaly of the left lamina of T2/T3 with no spinal canal narrowing.

The case was discussed with pediatric neurosurgery and they planned to admit him and they ordered CBC, cougulation,chemistry panel,put C collar, gave good analgesics and ordered MRI which was scheduled after one week.

MRI result was: there was redemonstration of subluxation of right lateral mass of C1 in relation to C2 lateral mass as well right occiptal condyle there was widening of atlanto-dental space.There was fluid signal intensity betwen the left lateral mass of C1 and C2. Also it showed improvement of previously described superior migration of odontiod process the reminder of cervical vertebra maintain normal alignment with redmonstration of parital non fused left anterior C2 vertebral body. There was segmentatrion fusion anomaly of the left lamina of T2/T3 with non fused posterior element of T2/T3.

One day after, neurosurgreon decided to proceed with closed reduction and keep the patient on collar.

The procedure was made by gentle traction and rotation of the neck to the left side until cervical spine became free movement and they felt that C1-C2 sublexation was reduced

During the stay he was stable with no complaint tolerating orally and was on cervical collar but still his neck tilted but no pain and moving his all limbs freely.

For follow up they requested cervical CT after 5 days of the surgery and it showed right lateral mass anterior subluxated C1-C2 as well right occiptal condyle again seen. Stable mild widening of atlanto-dental space again noted measures 2mm with mild superior migrated odontoid process, there was parital unfused left anterior C2 vertebral body and unchanged T2/T3 segmented fusionanomaly of left lamina associated with non fused posterior element of T2-T3.

After 6 days he came to outpatient clinics for follow up, patient was still complained of neck pain when sleeping and neck movement was still limited. surgery (occipto-cervical fixation) schedueled after 10 days.

during the surgery they did occiptio-cervical fixation from the occpito to C1 and C2 because the prevoius subluxation recurred qiukly after the operation because applying C-collar was difficult for him. After the surgery all screws were in good place and the subluxation was reduced between C1 and C2 and the patient was extubated and he was moving all his limbs and he was transferred to neuro intensive care unit in stable condition

3 days later they ordered cervical CT and X-ray for follow-up.

X-ray showed there was interval internal fixation of the upper cervical spine with two parallel spinning rods extending from the lower occiptal bone to the C2 level. On the lateral veiw the screw of the C1 was slightly projecting into the prevertebral soft tissue for clinical correlation.

Cervical CT showed status post internal fixation using four screws transfixing right anterolateral C1-C2 and right occipto condyle rotatory subluxation with normal Cervical alignment was acheived, the screw transfixing left lateral mass of C1 seen slighlty extending beyond the cortex anteriorly.

In all his outpatient clinics follow up he was doing fine no neck pain or tenderness and still on C-collar.

9 months ago they ordered another cervical CT and it showed there was stable appearance of posterior fixation of rotatory subluxation of C1 over C2. The screw transfixing left lateral mass of C1 was seen slightly extending beyond the cortex anteriorly however stable in appearance. No significant changes in the alignment of the cervical spine in comparison with the most recent CT, the predental space was normal, there was stable mild asymmetry between the lateral mass of the atlas and the odontoid more pronounced on the right side however central spinal canal was patent, there was persistant mild superior migrated odontoid process.

His last follow up in outpatint clinics was 2 months ago.Patient was doing fine, moving his all lims with no deficits and no neck pain or tenderness. Neck wound was dry and clean and well healed , the mother reported no more neck pain. Last CT showed no significant interval changes in the alignment of cerviacl spine and there was no concern from the mother

His next follow up appoaintment after 6 months.

Case 4 :  

This is a 7 years old school age girl, K/C of Down syndrome, and congenital heart disease; ventricular septal defect (VSD). Her past medical history was significant for a history of torticollis at an age of 2 years and resolved spontaneously, and her past surgical history was significant for myringotomy and ventilation tube placement after she had bilateral otitis media with effusion. On 01/08/2016; before 3 years, she presented to our emergency room (ER) at king Abdullah specialized children hospital, with 7 days history of wry neck to the right side after she had a witnessed trauma, she jumped and fell from a sofa to the ground, there was no history of loss of consciousness, vomiting, or active bleeding. On physical examination she was looking well, active, alert, her Glasgow Comma Scale was 15 out of 15, her vital signs were within the normal levels, her pupils were equal and reactive to light bilaterally, and there was no focal neurological deficit, and she has an obvious right sided torticollis and moderate pain with neck movement. In the emergency room she underwent a cervical spine CT which showed findings that suggest of the possible atlantoaxial rotatory subluxation; however, ligamentous injury cannot be ruled out for further evaluation by the cervical MRI. Then she was admitted for further investigations and evaluation, she was put on cervical collar, and underwent cervical spine MRI which showed that the main abnormality at the atlantoaxial articulation with findings suggestive underlying ligamentous injury, and no bony abnormality. So, she underwent manual reduction of atlantoaxial rotatory subluxation under general anesthesia (GA). Then she was discharged on Miami J collar. She presented multiple times to the ER, and she had multiple outpatient follow up and she was complaining of neck spasm; thus she received an intensive physiotherapy, After that, 2 months later she did a cervical spine CT which showed that there is a mild rotatory atlantoaxial subluxation, increased compared to the previous study, and prevertebral soft tissue thickening at C2. Therefore, she continued the same follow ups and physiotherapy. Then after another 2 months she did a follow up cervical spine CT which showed an interval worsening of rotatory atlantoaxial subluxation (probably type 2/3). This associated with cranial migration of C2 odontoid process to level of foramen magnum. Evaluation of the posterior fossa structures by MRI is recommended, if clinically warranted. And there was an improvement of the prevertebral soft tissue thickening with mild residual anterior to C2. So, the patient was admitted and underwent halo gravity traction, then 1 week later she underwent craniocervical fusion to C1 - C2 with halo traction removal. Then a post operation cervical spine MRI was done and showed that the previously noted significant basilar invagination of the odontoid process has significantly improved. And there is persistent posterior inclination of the dens with widening of the atlantoaxial joint measuring approximately 6 mm. And suggestive of residual occipito-cervical dissociation. Accordingly, as the patient is clinically stable, does not have any neurological deficits, and the most achievable degree of reduction was done during the surgery. Thus, now the patient is being followed closely in the clinic if she would developed weakness or myelopathy to consider anterior odontiodectony, which is a more extensive and morbid procedure. The patient tell last outpatient visit is clinically stable and no signs of weakness or myelopathy.