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La Causa de Los Adolescentes
Multidisciplinary analysis of a patient with a chronic disease: Adolescence, chronic disease, reception, negligence, psychic suffering, interdisciplinarity, juvenile idiopathic arthritis. Demonstrating the importance of multidisciplinary analyses and approaches to providing care and monitoring for a patient with a chronic disease.
A year-old adolescent in the teen ward at a public hospital in Rio de Janeiro doltoo with idiopathic juvenile arthritis. Chronic diseases are lengthy processes, with symptoms that develop gradually and multidimensional aspects.
Potentially disabling, they have long term effects on psychological, physiological and anatomical functions, with extremely limited chances of responding to curative treatment. Despite possible correction or compensation, negative impacts on the social contexts of patients remain severe.
The chronic patient requires special medical, psychological or educational care and specific facilities at school or at home. There is no consensus in the literature on this concept. Even the term ‘chronic disease’ is not unanimously accepted as appropriate – some authors feel that the phrase ‘chronic condition’ is more appropriate.
For Pless et al. Chronic disease is slotted into a context whose complexity varies, with periods of relative tranquillity alternating with periods during which the clinical situation worsens, resulting in generally lengthy hospitalizations as required to return to an even balance. It is natural that chronic conditions in themselves perpetuate a general feeling of insecurity in patients, particularly when a disease imposes physical, cognitive, social or other constraints at some point in life, undermining the patient’s self-esteem even more.
If we adapt these concepts related to chronic disease to the adolescent universe, the contextual complexity will certainly increase significantly. This paper presents a case study of a fifteen year old boy living in the streets, who was admitted to the teen ward of a municipal hospital in Rio de Janeiro, in order to investigate his clinical status of widespread pain and high fever every day.
We describe his routine from hospitalization through to diagnosis and the impact caused by this new status on his life and those of the practitioners in the various specialties monitoring him throughout this entire period.
We stress the extreme importance of a multidisciplinary approach for resolving this case, ratifying the need to ensure more specific institutional support programs that are attuned to the needs of this group of patients.
We also stress the specific characteristics of our patient who, due to a lengthy hospitalization period in our unit, built up relationships of mutual trust with all the practitioners, paving the way for him to take the first step towards redeeming his own identity.
CASE STUDY C is a teenage boy, 15 years old, who lived with his mother and seven siblings in a ramshackle and unhealthy home, reflecting the extreme poverty of the family. In terms of schooling, he knows only a few basic combinations of letters. Finally, he was living in an at-risk situation in the street, perhaps driven out by difficulties in his family and experimenting with drugs. In order to assist him, he was sent by the Guardians’ Council to a halfway house run by the Municipal Social Welfare Bureau.
As he needed medical care, he was referred to a front-line clinic State Civil Defense and Health Bureauwhere he was diagnosed with possible pneumonia, treated with IV antibiotics for three days and transferred to our unit, characterized as a ‘street dweller and crack user’. He spent 69 days in the teen boys ward. Initially, his general status was poor, sleepy and spending the entire day lying down, with constant fever.
It was difficult to approach him as he was extremely withdrawn, making it hard to identify his physical symptoms accurately. As he had been admitted with no companion, we were unaware of his exact clinical status: During his hospitalization, the interdisciplinary healthcare team was able to gradually learn about the real clinical symptoms of this patient.
With the results of the laboratory examinations leukocytosis with left deviation, evidence of very high inflammatory activities and chronic anemia and having dismissed other diagnoses tuberculosis, leukosis, bacterial endocarditis and other infectionsthe conclusion was reached that this was the case of juvenile idiopathic arthritis JIA in its systemic form Still’s disease. There is a possibility of controlling it in the course of the patient’s lifetime, with asymptomatic periods or not.
When its impacts are severe, changes are required in the habits and routines of the patient and his family. Juvenile Idiopathic Arthritis may progress through peaks or present as a single outbreak in the course of the patient’s lifetime. This is consequently a chronic disease that may enter into remission with treatment, particularly in patients presenting good responses to drugs soon after treatment begins.
In order to define the clinical diagnosis of a chronic disease, it is essential to obtain a detailed clinical history of the patient.
For children and adolescents the family is normally the best and most valuable source of information, obviously assuming that such children and adolescents are endowed with a minimally efficacious family structure where affection and protection are constant practice in the daily lives of these patients.
However, cases of negligence are noted.
LA CAUSA DE LOS ADOLESCENTES – FRANCOISE DOLTO.pdf
In this case, the boy was hospitalized in our unit for 69 days, and during this time his mother never visited him. We believe that the fact that the patient had been legally removed from the custody of his biological family – even before admission – streamlined the development of his progress, allowing social safety nets to interact with greater fluidity.
According to Joel Birman: Children attend school very little, and when they do so, they al forced to work in some way in order to contribute to family incomes. Their families are largely single-parent, consisting mainly adolsecentes mothers caring for offspring who often have different biological fathers. Launched very young into brutal social experiences, these children are forced to be adolescents and even adults at very young ages, precociously surviving terrible things that are almost impossible at their ages.
Alone due to negligence, he wandered through the streets with no purpose or constraints. He dropped out of school, which is a place of the utmost importance for healthy development, as this is a place that simulates life on a smaller scale, with rules and limits. Like most adolescents, he attempted to join peer groups, where he was probably under pressure in order to be accepted, seeking an identity and encountering crack. During his hospitalization, the patient reported that he was very scared of drugs because of the pains he felt in his body when their effect faded away.
He said that the pain was unbearable.
Now, after his definitive diagnosis, we wonder whether this pain was really caused by the drug, or whether it was his disease already ‘speaking louder’. This comparison is valid odlto as newborns die for something in order to be reborn into something else, including adolescents, who leave their dying childhood behind. He is in a chrysalis, with nothing to say to anyone, in the water. If we open a chrysalis, we find only water He seemed to want to protect himself as he did in the street. His blanket and position when kos down recall a cocoon.
He seemed to perceive that something would change. He was not accustomed to receiving attention and to have people looking at him in a situation of care rather that threat. He was facing a new situation in his life.
Little by little, the entire team arrived, and at no time did C appear hostile. Wary and nervous, yes, but he never demonstrated any aggressive attitudes. Even using a vocabulary belonging to the free df, he gradually accepted our welcome. The relatively long time between his admission to hospital and his diagnosis allowed links of trust to build up between the patient and the team.
The Child and the Adolescent have the right to life and health through the implementation of public social welfare policies that allow healthy births and harmonious development under decent living conditions. This case ratifies the importance of guiding efforts through intersectorial actions linked to the deployment of public policies, in order to ensure comprehensive healthcare actions.
La causa de los adolescentes – Françoise Dolto – Google Books
We believe that the life of this adolescent was saved to a great extent by the strong and affectionate links that he built up with the professionals working at the Halfway House, established before he was admitted to hospital and proven by the presence and commitment of these professionals to him and to ourselves throughout the entire process, all intended acolescentes seek the best possible outcome for his case, which was discussed at a interdisciplinary war meeting, as well as on other occasions with the Halfway House coordinator and the patient himself.
The clinical diagnosis had been defined. However, a deadlock occurred: Although everything was explained to this adolescent, he did not feel comfortable with the idea. In order to meet his needs, a place was found with a foster family. Consequently, we feel that sharing knowledge through interdisciplinary actions and the commitment of all the players involved in ccausa various tiers of government who were engaged in monitoring this case, play a vital role in ensuring the best possible care for this adolescent, opening up new and real prospects for better days to come.
Framework for identifying children who have chronic conditions – the case for a new definition. The J Pediatr ; 3: Chronic illness in childhood: Pediatrics ; 58 1: Cadernos sobre o mal: Psychologist, Piedade Municipal Hospital.
Social Worker, Piedade Municipal Hospital.