READING A CLOSED BOOK

Mr. y. is a 30-year-old man with prune-belly syndrome (a serious metabolic disorder) and secondary chronic renal failure. The patient was born out of wedlock, abandoned by his mother. Prunebelly syndrome was evident at birth. The patient was placed in a foster home, but the multiple medical problems of his condition necessitated admission to a state hospital, where he remained for approximately 15 years before transfer to a state school for the retarded.

The patient's renal problems have been chronic, severe, recurrent, and nearly untreatable. He had had nine separate major urologic surgical procedures, including total removal of a left kidney at the age of 7. His course has been complicated by numerous infections, imbalances of his electrolytes and metabolism, hypertension, and general progressive deterioration. In the several years before admission, he developed a left brain hemorrhage after a fall, which required surgery; he then required the same procedure after another fall a year later. Regrettably, a seizure disorder developed (which is often the case in such injuries) and the patient is now on anticonvulsant medication. The patient was recently begun on chronic hemodialysis because of the functional failure of his kidney. However, the course of his treatment has been extremely stormy with the patient being both despondent and uncooperative. Repeated shunts to connect the patient to the dialysis machine have had to be placed in the patient's blood vessels because he frequently manipulates the shunt tubing and has had recurrent infections around the shunt site.