Nossa proposta consiste em realizar uma investigação teórica em torno do conceito de trauma na obra freudiana, assim como das problemáticas a que responde. Objetivamos pesquisar se a teoria do trauma teria de fato desaparecido no período situado entre o abandono da teoria da sedução e os construtos de 1920, como defendem alguns autores na literatura psicanalítica. Nossa hipótese é que a noção de trauma teria continuado a sustentar a teoria freudiana do sofrimento psíquico, não só por meio de aparições esporádicas do conceito nesse período, mas também, implicitamente, por meio das problemáticas a ele relacionadas como a da etiologia das neuroses e dos grandes casos clínicos de Freud: Dora, Homem dos Ratos e Homem dos Lobos. Assim, primeiramente rastreamos a noção de trauma e suas ramificações ao longo da obra e, em seguida, fizemos um estudo desses três casos clínicos, em busca de possíveis configurações traumáticas na história de seus protagonistas. Chegamos ao entendimento de que Freud não trata sempre do mesmo tipo de trauma ao longo dos seus escritos: o termo se mantém, mas com acepções diferentes. Haveria, assim, subtipos do trauma implícitos no discurso freudiano trauma por efração, trauma como falta de mediação entre fantasia e realidade e, ainda, pistas para se pensar um trauma como falha narcísica. A partir desses subtipos, abordamos as consequências clínicas da releitura desse conceito, do ponto de vista do diagnóstico diferencial. Em seguida, apontamos como o aspecto eminentemente econômico que permeia a categoria de trauma influiu na visão de Freud sobre os dispositivos utilizados pelo analista na clínica. Acompanhar as ramificações, assim como o alcance clínico da noção de trauma, consiste em uma tarefa que pode nos oferecer ferramentas teóricas para compreensão dos tipos de constelações traumáticas subjacentes aos sofrimentos intoleráveis daqueles que procuram a clínica psicanalítica / Our proposal is to perform a theoretical investigation regarding the concept of trauma in Freuds work, as well as the set of problems it responds to. We aimed to research if the theory of trauma would have in fact disappeared in the period between the abandon of the seduction theory and the constructs of 1920, as defended by some authors in the psychoanalytic literature. Our hypothesis is that the notion of trauma would have continued to sustain the Freudian theory of psychic suffering, not only through sporadic appearances of this concept during this period, but also, implicitly, by means of the set of problems related to it as the etiology of neurosis and of the major clinical cases of Freud: Dora, Rat Man and Wolf Man. Thus, primarily we searched for the notion of trauma and its ramifications throughout the wok and, afterwards, we performed a study of these three clinical cases, looking up for possible traumatic configurations in the history of their protagonists. We came to the understanding that Freud does not always treat the same kind of trauma throughout his writings: the term remains, but with different meanings. There would be, therefore, implicit subtypes of trauma in the Freudian discourse trauma by rupture, trauma as lack of mediation between fantasy and reality and, yet, clues to think of a trauma as a narcissistic fault. From these subtypes, we approached the clinical consequences of the reinterpretation of this concept, from the differential diagnosis viewpoint. Next, we pointed out how the eminently economic aspect that permeates the category of trauma influenced in Freuds view about the devices used by the analyst in the clinic. Following the ramifications, as well as the clinical scope of the notion of trauma, consists in a task that may offer us theoretical tools for the understanding of the types of traumatic constellations underlying the intolerable suffering of those who look for the psychoanalytic clinic

Objetivo: describir las características clínicas, tratamiento y el pronóstico de diferentes casos clínicos revisados durante el Internado Médico en el período junio 2021 a febrero 2022 en los establecimientos de salud: Hospital Nacional Dos de Mayo, Hospital María Auxiliadora, Policlínico Chorrisalud y Centro Médico Fesalud. Metodología: se realizó un estudio descriptivo y analítico de casos clínicos acumulados de diferentes establecimientos de salud y de los que considero obtuve los aprendizajes más significativos. Estos establecimientos fueron el Hospital Nacional Dos de Mayo y el Hospital María Auxiliadora, estos son establecimientos estatales de categoría III-1; también, del Policlínico Chorrisalud y el Centro Médico Fesalud, los cuales pertenecen a establecimientos privados de categoría I-3. Los casos se obtuvieron de las especialidades de Ginecología- Obstetricia, Cirugía - Especialidades, Pediatría – Neonatología y Medicina Interna. Resultados: se describen 30 casos clínicos, de los cuales el 50 % provienen de establecimientos de categoría III-1; mientras que, el otro 50 % han sido recopilados de los establecimientos de categoría I-3. Durante la práctica clínica se pudo observar las fortalezas y limitaciones de cada establecimiento. Además, se pudo prestar atención a los aciertos, fallos y posibilidades que tenía el personal de salud de cada establecimiento. Conclusiones: en conclusión, este trabajo demuestra la preparación de un interno de medicina antes de llegar a ser buen médico bajo tres premisas. Primero, tiene presente que trata personas con enfermedades y no solo enfermedades; segundo, demuestra sus capacidades académicas para tratar y manejar las enfermedades de sus pacientes; y por último desarrolla liderazgo para saber trabajar en grupo en beneficio del paciente. / Objective: to describe the clinical characteristics, treatment and prognosis of different clinical cases reviewed during a Medical Internship between June 2021 to February 2022 in the following health providers: Dos de Mayo National Hospital, María Auxiliadora National Hospital, Chorrisalud Clinic and Fesalud Medical Center. Methodology: a descriptive analysis and study of accumulated clinical cases from different health centers was carried out. Cases were selected based on the author’s criteria according to which were considered to contribute significantly with medical training. These establishments were Dos de Mayo National Hospital and María Auxiliadora National Hospital, categorized as III-1 per state legislation. Chorrisalud Clinic and Fesalud Medical Center, both private establishments, shared I-3 category. The cases will be collected from the specialties of OB-GYM, Surgery (general and specialties), Pediatrics, Neonatology and Internal Medicine. Results: 30 clinical cases were described, from which 50% were retrieved from III-1 category centers and the remaining 50% collected from category I-3 establishments. It was possible to observe the strengths and limitations of each establishment during clinical practice. In addition, it was possible to pay attention to the successes, failures and possibilities that the health personnel of each establishment possessed. Conclusions: in conclusion, this portfolio exemplifies and supports three important arguments for a medical intern to have before graduating. First, keeping in mind to treat the patient as a whole and not just an isolated illness; second, to demonstrate academic ability in treatment and management of said patient’s illness; lastly to establish leadership and knowing how to work as a team for the benefit of the patient. / Trabajo de Suficiencia Profesional

Objetivo: Describir y hacer un análisis crítico de los casos clínicos que formaron parte significativa del aprendizaje obtenido como interno de medicina durante los meses de rotación en el Centro de Salud Gustavo Lanatta Luján y el Hospital Nacional Dos de Mayo, durante el periodo de junio 2021 a febrero 2022, los cuales contribuyeron a mi formación como futuro médico cirujano. Metodología: Se realizó un estudio observacional, de tipo descriptivo y analítico de los casos que consolidaron la experiencia clínica obtenida durante el internado médico Resultados principales o hallazgos: Recopilación de 30 casos clínicos, que fueron presentados de manera descriptiva. Los cuales evidencian de forma global los principales aprendizajes obtenidos en la práctica clínica, tales como: comunicación oral, pensamiento crítico y analítico, manejo de información y profesionalismo. Conclusiones: El internado médico es una etapa fundamental en la formación de todo profesional del campo de la salud, en el cual se sintetizan, integran y aplican los conocimientos adquiridos durante los años previos. Actualmente, el contexto de pandemia nos ha permitido ser parte del desarrollo de la ciencia, experimentando de primera mano la evolución de una enfermedad, la cual generó cambios a los que se debió adaptar, no solo el personal de salud, sino también la población en general; asimismo atravesamos una etapa en la cual día a día se emitían nuevos avances científicos, los cuales debíamos analizar y aplicar en los diferentes campos con la finalidad de lograr el bienestar de nuestros pacientes. Finalmente, se obtuvo un aprendizaje íntegro, enfocado en el paciente, respetando y considerando sus creencias y culturas; fortaleciendo la relación médico paciente y la comunicación activa, puesto que en nuestra profesión se trata personas, no solo patologías. / Objective: To describe and make a critical analysis of the clinical cases that formed a significant part of the learning obtained as a medical intern during the months of rotation at Gustavo Lanatta Luján Health Center and Dos de Mayo National Hospital, during the period of June 2021 to February 2022, which contributed to the training as a future physician. Methodology: An observational, descriptive and analytical study of the cases that consolidated the clinical experience obtained during the medical internship. Main results or findings: Compilation of 30 clinical cases, which were presented using descriptive instruments. Which evidence the main learning obtained in clinical practice, such as: oral communication, critical and analytical thinking, information management and professionalism. Conclusions: The medical internship is a fundamental stage in the training of all professionals in the health field, in which the knowledge acquired during the previous years is synthesized, integrated and applied. Currently, the pandemic context has allowed us to be part of the development of science, experiencing first-hand the evolution of a disease, which generated changes to which not only health personnel had to adapt, but also the population in general; Likewise, we went through a stage in which new scientific advances were issued day by day, which we had to analyze and apply in the different fields in order to achieve the well-being of our patients. / Trabajo de Suficiencia Profesional

La presentación de 30 casos clínicos seleccionados por considerar que me dejaron aprendizajes significativos como interno de medicina durante las diversas rotaciones en el Hospital nacional Dos de Mayo y en el Centro de Salud Gustavo Lanatta Luján. Se describen los diagnósticos presuntivos, exámenes de laboratorio solicitados, diagnósticos finales, posibles complicaciones que pueden presentar las diversas patologías, tratamiento específico o criterio de referencia a un centro de salud de mayor complejidad y análisis crítico de cada caso. Objetivo: describir y hacer un análisis crítico a propósito de los casos clínicos a que estuve expuesto como interno de medicina y que contribuyeron a mi formación con aprendizajes significativos. Metodología: trabajo descriptivo y analítico de la experiencia clínica obtenida durante el internado médico Resultados principales o hallazgos: se describen 30 casos clínicos reportados en el Hospital Nacional Dos de Mayo y en el Centro de Salud Gustavo Lanatta Luján. Se rescata la capacidad de identificación de patologías prevalentes en el primer nivel de atención identificando aquellas con indicación de referencia a un centro de salud con mayor complejidad resolutiva. Conclusiones: el interno de medicina logra aprender y reconocer las limitaciones que presenta el sistema de salud peruano, se evidencia en muchos casos una diferencia marcada entre las decisiones sugeridas por la literatura actual y la práctica diaria, pero se evalúa y busca la mejor alternativa para ser brindada al paciente. Se observa cambios de tratamiento eligiendo fármacos de tercera línea o fármacos con los que notaron mejoría en pacientes previos. Se observa que muchas veces los pacientes deben recurrir a centros privados para la atención oportuna, debido a la demora en las citas del sistema de salud peruano. / A presentation of 30 clinical cases selected from my medical internship rotation at “Dos de Mayo” National Hospital and “Gustavo Lanatta Luján” Primary Care Center. Presumptive diagnoses, laboratory tests, specific diagnosis, illness complications; specific treatment or referral criteria to a more complex health center and critical analysis of each case are described. Objective: Detailed description and critical analysis of the clinical cases I encountered as a medical intern was performed. Therefore, further contributing with my medical training and enhancing my learning process. Methodology: a descriptive and critical analysis of clinical experience encountered during a period of 10 months, which accounts for a medical internship. Main results or findings: 30 clinical cases reported at Dos de Mayo National Hospital and Gustavo Lanatta Luján Health Center are described. Ability to identify prevalent pathologies at the first level of care was assessed by identifying patients with indication of referral to health center with greater complexity. Conclusions: The author, a medical intern, learned and recognized limitations presented by the Peruvian Healthcare system. There is a difference between clinical decision- making suggested by current literature and daily practice. / Trabajo de Suficiencia Profesional

Objetivo: describir la experiencia académica en la práctica clínica durante el internado médico en el período junio 20021 a febrero 2022 en los establecimientos de salud: Hospital Nacional Dos de Mayo (HN2DM) y Centro Materno Infantil Ollantay (CMI) y mostrar los aprendizajes más significativos que obtuve durante ese periodo. Metodología: trabajo descriptivo y analítico de la experiencia clínica obtenida en el Hospital Nacional Dos de mayo en el servicio de hospitalización sala Virgen del Carmen de Medicina interna y en el servicio de Cirugía en la sala I4 del mismo hospital. Asimismo, de experiencias obtenidas en el CMI Ollantay en la consulta externa de pediatría y medicina general durante el internado médico Resultados principales: Se describen 30 casos clínicos evaluados en Hospital Nacional Dos de Mayo y CMI Ollantay, la mayoría de los casos 40% pertenecen al servicio de Cirugía General del HN2DM, 33.3% del servicio de Medicina Interna del HN2DM, 20 % del consultorio externo de Pediatría del CMI Ollantay y 6.6% de los casos fue de consultorio externo de Medicina General del CMI Ollantay. Durante las experiencias recogidas en los establecimientos de salud se pudo exponer las fortalezas y limitaciones de cada servicio, asimismo el rol participativo que tiene el personal de salud de forma integral para el diagnóstico precoz, tratamiento oportuno y rehabilitación de los pacientes. Conclusiones: la atención integral del paciente depende mucho de cada establecimiento de salud, esta varía mucho según su capacidad resolutiva. Durante el internado se obtuvo experiencias enriquecedoras durante las practicas diarias en los establecimientos de salud, como ver sonreír al paciente luego de la consulta médica, ayudando al paciente a aliviar y/o curar su enfermedad, además de aprender nueva habilidades de procedimientos médicos, como realizar extracción de sangre venosa y arterial, paracentesis, suturas complejas, colocación de sondas nasogástricos, realizar maniobras de resucitación. Asimismo, se pudo obtener mayor conocimiento para el manejo y tratamiento de los pacientes, según su condición de salud. / Objective: To describe the academic experience in clinical practice during the medical internship in the period June 20021 to February 2022 in the health establishments: Dos de Mayo National Hospital and Ollantay Maternal and Child Center (CMI) and show the most significant learning that I obtained during that period. . Methodology: Descriptive and analytical major report of the clinical experience obtained at the Dos de Mayo National Hospital in the hospitalization service of the Virgen del Carmen Internal Medicine room and in the Surgery service in room I4 of the same hospital. Likewise, from experiences obtained in the CMI Ollantay in the external consultation of pediatrics and general medicine during the medical internship. Main results: 30 clinical cases evaluated at Hospital Nacional Dos de Mayo and CMI Ollantay are described, most of the cases 40% belong to the General Surgery service of the HN2DM, 33.3% to the Internal Medicine service of the HN2DM, 20% to the outpatient Pediatrics office of the CMI Ollantay and 6.6% of the cases were from the General Medicine outpatient clinic of the CMI Ollantay. During the experiences collected in the health establishments, the strengths and limitations of each service could be exposed, as well as the participatory role that health personnel have in an integral way for early diagnosis, timely treatment and rehabilitation of patients. Conclusions: The comprehensive care of the patient depends a lot on each health establishment; this varies a lot according to its resolution capacity. During the internship, enriching experiences were obtained during daily practices in health establishments, such as seeing the patient smile after the medical consultation, helping the patient to alleviate and/or cure their illness, in addition to learning new skills of medical procedures, such as perform venous and arterial blood extraction, paracentesis, complex sutures, placement of nasogastric tubes, perform resuscitation maneuvers. Likewise, it was possible to obtain greater knowledge for the management and treatment of patients, according to their health condition. / Trabajo de Suficiencia Profesional

La presentación de 30 casos clínicos durante el internado en el Centro Médico Naval Mayor Cirujano Mayor Santiago Távara. Se describen los diagnósticos presuntivos, exámenes de laboratorios solicitados, diagnósticos finales, complicaciones, tratamiento específico, y reflexiones significativas para cada caso Objetivo: describir y hacer un análisis crítico a propósito de los casos clínicos que estuve expuesta como interna de medicina y que contribuyeron a mi formación con aprendizajes significativos. Metodología: trabajo descriptivo y analítico de la experiencia clínica obtenida durante el internado médico Resultados principales o hallazgos: se describen 30 casos clínicos reportados en el Centro Médico Naval. Se rescata la capacidad de diagnóstico precoz y manejo oportuno de cada patología. Conclusiones: los aprendizajes más significativos a lo largo de mi internado, han sido: realizar el diagnóstico precoz de enfermedades prevalentes, conocer el manejo de las patologías más frecuentes, aprender técnicas quirúrgicas, y utilizar los recursos diagnósticos de forma eficiente. / The presentation of 30 clinical cases during the internship at the Naval Medical Center Major Surgeon Santiago Tavara. The presumptive diagnosis, requested laboratory tests, final diagnoses, complications, specific treatment, and criteria analysis of each case are described. Objective: to describe and present a critical analysis of the clinical cases to which I was exposed as a medical intern and that contributed to my training with significant learning. Methodology: a descriptive and critical anaylisis of the clinical experience obtained during the medical internship. Main results: 30 clinical cases reported at the Naval Medical Center are described. The capacity for early diagnosis and timely management of each pathology is rescued. Conclusions: the most significant learnings throughout my hospital stay have been: to make an early diagnosis of prevalent diseases, to know how to manage the most frequent pathologies, to learn surgical techniques and to use diagnostic resources efficiently. / Trabajo de Suficiencia Profesional

[pt] Esta dissertação trata da importância do significante em interpretações e construções na clínica psicanalítica, partindo do estudo de fragmentos de casos clínicos de psicanalistas como Freud, Lacan e Jean Allouch. Suas bases concentram-se na maneira como a linguagem é tomada na formulação do inconsciente por Freud e depois por Lacan. No que chama de retorno a Freud, Lacan procura recolocar a psicanálise em seu caminho: o da linguagem, relendo os textos que considera canônicos sobre os sonhos, os atos falhos e os chistes. Para realizar o estudo, segui o caminho de Lacan pela linguística com Saussure, Jakobson, Benveniste, Damourette, Pichon e outros linguistas e gramáticos que foram importantes referências em suas formulações. Procurando apreender o Freud lido por Lacan, que determinou suas reformulações na psicanálise, mais especificamente na direção do tratamento psicanalítico, atravessei também textos de Lacan nos quais ele começa discutindo a fala, no campo da linguagem, voltado para a transmissão da psicanálise e para a oposição entre duas concepções de tratamento e a formação do psicanalista. Em seus últimos seminários, acaba por decidir deixar a linguística para os linguistas e cunhar o termo linguisteria para falar de que linguagem se trata na psicanálise. A partir de fragmentos de casos clínicos, refleti acerca da relevância de determinados significantes, que aparecem durante os tempos do tratamento psicanalítico nos quais a intervenção do analista faz com que o analisante possa abandonar a fixidez de sentido e empreender o caminho de construção de seu fantasma até a sua travessia. Destaquei alguns conceitos utilizados por Freud (Wortfuge- Worfugen-Wortfügung, Wortklang, Entstellung, Konstruktion, Phantasieren, dentre outros), com os quais se quis entender a técnica psicanalítica, a partir das interpretações freudianas de sonhos, chistes e atos falhos, e avançar nas elaborações lacanianas na direção do tratamento, interpretação, ato analítico. / [en] This thesis studies the role of the signifier in interpretations and constructions in psychoanalytical treatments, taking into consideration the analysis of fragments of clinical cases from psychoanalysts like Freud, Lacan and Jean Allouch, among others. This work is based on the way language was taken by Freud and later by Lacan in the formulation of the concept of the unconscious. In Lacan s Retour à Freud he tries to put psychoanalysis back on track, the language path, by rereading the texts he considers canonical about the interpretation of dreams, parapraxis and wits. To accomplish this study, I followed Lacan s steps through linguistics with Saussure, Jakobson, Benveniste, Damourette, Pichon and other linguists and grammarians that were important to his psychoanalytical formulations. In order to understand Freud read by Lacan, which determined his reformulations on psychoanalysis, specifically in regards to treatment, I took into account texts in which Lacan begins to discuss speech, in the field of language, focused on the transmission of psychoanalysis and on the opposition between two existing conceptions of the treatment and the formation of the psychoanalyst. In his last seminars, Lacan ends up deciding to leave linguistics to the linguists and to coin the term linguistery to state which language psychoanalysis deals with. Based on fragments of clinical cases, I reflected on the relevance of certain signifiers that appear on the course of different treatments in which the analysts intervention enabled the analysand to abandon a previously fixed meaning and undertake a new way to the construction of his phantasy up to its crossing. Some of the signifiers used by Freud (Wortfuge-Worfugen- Wortfügung, Wortklang, Entstellung, Konstruktion, Phantasieren, among others) helped me understand the psychoanalytical technics through Freud s interpretations of dreams, wits, parapraxis and move on to lacanian elaborations on psychoanalytical treatment, interpretation, analytical act.