had
undergone
cardioversion
recently.
no
to
the
apparent
care
coronary
active
unit
The
parenchymal
and
patient
was
ad-
Electrocardiographic study revealed atrial flutter and fibrillation with variable atrioventricular block. The atrial rate was 280 impulses per minute, and the ventricular rate varied between 90 and 120 impulses per minute. The patient remained in the coronary care unit for approximately ten hours and was monitored continuously. The vital signs remained stable, and his arrhythmia did not change, except for a slower ventricular response. Rhythm strips also revealed aberrant conducted beats. A chest x-ray film showed mitted
monitored.
lesion;
the
left
ventride
The most impressive fact about this that he continuously and repeatedly demanded and requested cardioversion as a method of treatment, claim-
appeared patient
ing
hypertrophic.
was
that
this was the only thing that could help him. Reexplanations on the part of the medical and nursing staff were of no avail, and when the patient finally convinced himself that cardioversion would not be available to him on demand, he signed himself out against medical advice and left the medical center, in good condition. Additional inquiries into this patient’s history revealed that he also had come to an affiliated hospital nine days earlier, with similar complaints, and demanded to undergo cardioversion. Furthermore, on Nov 17, 1974, nine days after he signed himself out of our medical center, the patient again came to the emergency room complaining of chest pain and palpitations and gave a history of rheumatic fever since the age of 12 years. The physical examination in the emergency room at that time revealed a well-built man in no distress, with an irregular pulse rate of 122 beats per miute, blood pressure of 140/100 mm Hg, and vesicular breath sounds. The patient demanded to undergo cardioversion by the medical staff as the only method of treatment. Electrocardiographic studies revealed atrial flutter with varying atrioventricular conduction, unchanged from the previous record. The patient signed out of the emergency room when he realized that the medical staff would not offer cardioversion on demand. Three months later, I engaged in a follow-up telephone conversation with a relative of the patient, probably his wife, who was unwilling to identify herself as such. She recalled that during 1% months in 1974, the patient had peated
undergone
at
least
seven
cardioversions
at
various
New
York
City metropolitan hospitals, which maintained his rhythm as regular for no more than one or two days, after which he invariably reverted back to his irregular rhythm. This lady did not know exactly how many cardioversions the patient had had in the last 18 months, but she did know, as a fact, that he went from hospital to hospital in the metropolitan area demanding and, many times, receiving cardioversions. I advised the patient through this intermediary to stop running from hospital to hospital for his own good, and she promised me that she would transmit the message. Additional telephone verification was obtained through a telephone inquiry to eight large teaching hospitals in metropolitan New York City where the patient was hospitalized between January and November 1974. The length of the hospitalization was, in each and every case, one day or less and was terminated by the patient leaving the hospitals against medical advice. DiscussloN
The profile tient includes
of such a professional cardioversion the following characteristics: an
CHEST, 71: 3, MARCH,
1977
paability
to
describe
medical
symptoms
and
nomenclature;
history
of
day
or less
tions
in the
numerous in
many on
and
ever,
is the
persistent
single
method
of
with
( one
hospitalizations
);
hospitals
documented
suspicious
anterior
surface
anxiety.
versatility occupation;
history; the
nervousness
and
white-collar
short-term
patient’s
cardioversion
signs,
a
a
contradicmarks
of
the
of recent chest;
and
The
main
characteristic,
how-
demand
for
cardioversion
as the
treatment.
In summary, medical and nursing staff should be suspicious whenever a patient requests or demands cardioversion as the sole method of treatment. Further inquiry should be made regarding the veracity of alleged symptoms and signs, and careful scrutiny of the patient’s history of treatments should be undertaken. Telephone contacts requesting additional information must be initiated with other hospitals, emergency rooms, and physicians, as well as with members of the patient’s family. The presence of cutaneous lesions resembling attempted or unsuccessful therapy via electrical
countershock
raises
senting syndrome. for a psychiatric tervention.
further
No hesitation consultation
Reuben
1 Zipes DP: The clinical diovase Clin 2:239-260,
Spontaneous
the
Tizes,
M.D.,
application 1970
MPH.,
pre-
F.C.C.P. Hewlett, NI’
of cardioversion.
Malignant
Recently,
English
the
the need crisis in-
Car-
with
Melanoma
Editor: we
malignant thorax
about
Pneumothorax
Metastatic To
doubt
should delay geared toward
observed
melanoma
a patient
in
whom
This
developed.
has
with
widespread
spontaneous
not
been
pneumo-
reported
in
the
literature. CASE
REPORT
A 46-year-old white man had undergone local excision of a 1.5-cm malignant melanoma of the scalp in August 1972. Twelve months later, it metastasized to the right submandibular lymph node; this was subsequently excised. In June 1974, the patient was hospitalized because of anorexia and weakness. Prominent hepatosplenomegaly was noted on examination and scan; the latter showed multiple filling defects. Chest x-ray films revealed a 1.8-em nodule in the left hilar area. Proctoscopy disclosed a metastatie melanoma located 14 cm above the anus. The patient received two courses of polychemotherapy with hydroxyurea, 1,3-bis(2-chloroethyl)-1-nitrosourea, dimethyltriazenoimidazolecarboxamide, and vineristine in July and August; however, hepatosplenomegaly increased. A chest x-ray film in late August
Twelve
showed
days
moderate
later,
left
the
pleural
patient
effusion.
suddenly
developed
COMMUNICATIONS TO THE EDITOR
sharp
435
pain in the left side of the chest and dyspnea; a chest x-ray film disclosed a moderate left pneumothorax visible above the left pleural effusion ( Fig 1 ). A chest tube was inserted but the left lung failed to reexpand. The patient died four days later. DiscusSioN Spntaneous
course
pneumothorax
of
primary
lung
manifestation.
In
pneumothorax
was
same
side
as the
middle-aged
review1
was
secondary
The
majority
than
reported
pneumothorax
tended
known
to occur
to have
pulmonary
had
lesions.
in one-third pneumothorax
of
lungs,5
with
in
frequently
lungs.
sarcomas.
The
patients
peripheral
who
metastatie
pneumothoraces
Wilms’
the
hydrothorax
of the
in younger
the reported occurred with
on
occurred
more
been
multiple
Bilateral
the
and
tumors
have
the
initial
eases.
primary
cases
in an
subject,
by
occurs
with
of such
this
of
unilateral
complicated
of the
late as
commonly
pneumothorax
with
rarely,
tumor,
and
in half
occur
or,
always
primary
Spontaneous
the
recent
almost
men,
or pyrothorax
were
a
may
cancers
developed
cases. Less commonly, carcinoma metastatic to
tumor,2’5
or
with
lympho-
sarcoma.3
The occurrence of spontaneous pneumothorax in our patient is most likely due to pulmonary and pleural involvement by the metastatic melanoma. Kai-Yiu
Yeung,
M.D.,#{176}Hematology-Oncology Veterans Administration
John D. Bonnet,
and
M.D.,
Hematology-Oncology Scott
#{176}Presently at Veterans Reprint requests: Dr. Veterans Administration
Section Center
Section
and
White Clinic Temple, Tex
Administration Center, Hampton, Va. Yeung, Hematolagy-Oncology Section, Hospital, Hampton, Va 23667 REFERENCES
1 Yeung KY, Bonnet JD: Bronchogenic carcinoma u.s spontaneous pneumothorax: Case report of literature. Cancer, to be published 2
l)’Ango
Cl.
lannaccone
a complication T13O S
of
Dines
pulmonary
436
Cortese
J
Am
86:1092-1102, DE,
Spontaneous
of pulmonary
childhood.
Med 3
C:
metastases Roentgenol
in malignant Radium
Ther
neoplasms
COMMUNICATIONS
Brennan
predisposing
MD,
et
al:
to spontaneous
tuNuel
TO THE EDITOR
Malignant
pneumo-
Mayo EA, with
soeiated as
1961 DA,
thorax. 4 Lodmell
presenting with review
pneumothorax
FlGuisx 1. Chest x-ray film ( Sept 6, 1974). A ( top ), Pneumothorax with collapsed lung and hydrothorax in left hemithorax. B (bottom), Enlarged view of left upper pulmonary field, showing left pneurnothorax and outline of ateleetatie lung.
Clin Proc 48:541-544, Capps SC : Spontaneous metastatie
sarcoma:
1973 pneumothorax A report
of
three
ascases.
Radiology 52:88-93, 1949 5 Sherman RS, Brant EE : An x-ray study of spontaneous pneumothorax due to cancer metastases to the lungs. Dis Chest 26:328-337, 1954 6 Spittle MF, Heal J, Harmer C, et al: The association of spontaneous
bone
tumours
pneumothorax
of children.
with
pulmonary
Clin
Radiol
CHEST,
metastases
19:400-403,
71:
in
1968
3, 1977 MARCH,
undergone
cardioversion
recently.
no
to
the
apparent
care
coronary
active
unit
The
parenchymal
and
patient
was
ad-
Electrocardiographic study revealed atrial flutter and fibrillation with variable atrioventricular block. The atrial rate was 280 impulses per minute, and the ventricular rate varied between 90 and 120 impulses per minute. The patient remained in the coronary care unit for approximately ten hours and was monitored continuously. The vital signs remained stable, and his arrhythmia did not change, except for a slower ventricular response. Rhythm strips also revealed aberrant conducted beats. A chest x-ray film showed mitted
monitored.
lesion;
the
left
ventride
The most impressive fact about this that he continuously and repeatedly demanded and requested cardioversion as a method of treatment, claim-
appeared patient
ing
hypertrophic.
was
that
this was the only thing that could help him. Reexplanations on the part of the medical and nursing staff were of no avail, and when the patient finally convinced himself that cardioversion would not be available to him on demand, he signed himself out against medical advice and left the medical center, in good condition. Additional inquiries into this patient’s history revealed that he also had come to an affiliated hospital nine days earlier, with similar complaints, and demanded to undergo cardioversion. Furthermore, on Nov 17, 1974, nine days after he signed himself out of our medical center, the patient again came to the emergency room complaining of chest pain and palpitations and gave a history of rheumatic fever since the age of 12 years. The physical examination in the emergency room at that time revealed a well-built man in no distress, with an irregular pulse rate of 122 beats per miute, blood pressure of 140/100 mm Hg, and vesicular breath sounds. The patient demanded to undergo cardioversion by the medical staff as the only method of treatment. Electrocardiographic studies revealed atrial flutter with varying atrioventricular conduction, unchanged from the previous record. The patient signed out of the emergency room when he realized that the medical staff would not offer cardioversion on demand. Three months later, I engaged in a follow-up telephone conversation with a relative of the patient, probably his wife, who was unwilling to identify herself as such. She recalled that during 1% months in 1974, the patient had peated
undergone
at
least
seven
cardioversions
at
various
New
York
City metropolitan hospitals, which maintained his rhythm as regular for no more than one or two days, after which he invariably reverted back to his irregular rhythm. This lady did not know exactly how many cardioversions the patient had had in the last 18 months, but she did know, as a fact, that he went from hospital to hospital in the metropolitan area demanding and, many times, receiving cardioversions. I advised the patient through this intermediary to stop running from hospital to hospital for his own good, and she promised me that she would transmit the message. Additional telephone verification was obtained through a telephone inquiry to eight large teaching hospitals in metropolitan New York City where the patient was hospitalized between January and November 1974. The length of the hospitalization was, in each and every case, one day or less and was terminated by the patient leaving the hospitals against medical advice. DiscussloN
The profile tient includes
of such a professional cardioversion the following characteristics: an
CHEST, 71: 3, MARCH,
1977
paability
to
describe
medical
symptoms
and
nomenclature;
history
of
day
or less
tions
in the
numerous in
many on
and
ever,
is the
persistent
single
method
of
with
( one
hospitalizations
);
hospitals
documented
suspicious
anterior
surface
anxiety.
versatility occupation;
history; the
nervousness
and
white-collar
short-term
patient’s
cardioversion
signs,
a
a
contradicmarks
of
the
of recent chest;
and
The
main
characteristic,
how-
demand
for
cardioversion
as the
treatment.
In summary, medical and nursing staff should be suspicious whenever a patient requests or demands cardioversion as the sole method of treatment. Further inquiry should be made regarding the veracity of alleged symptoms and signs, and careful scrutiny of the patient’s history of treatments should be undertaken. Telephone contacts requesting additional information must be initiated with other hospitals, emergency rooms, and physicians, as well as with members of the patient’s family. The presence of cutaneous lesions resembling attempted or unsuccessful therapy via electrical
countershock
raises
senting syndrome. for a psychiatric tervention.
further
No hesitation consultation
Reuben
1 Zipes DP: The clinical diovase Clin 2:239-260,
Spontaneous
the
Tizes,
M.D.,
application 1970
MPH.,
pre-
F.C.C.P. Hewlett, NI’
of cardioversion.
Malignant
Recently,
English
the
the need crisis in-
Car-
with
Melanoma
Editor: we
malignant thorax
about
Pneumothorax
Metastatic To
doubt
should delay geared toward
observed
melanoma
a patient
in
whom
This
developed.
has
with
widespread
spontaneous
not
been
pneumo-
reported
in
the
literature. CASE
REPORT
A 46-year-old white man had undergone local excision of a 1.5-cm malignant melanoma of the scalp in August 1972. Twelve months later, it metastasized to the right submandibular lymph node; this was subsequently excised. In June 1974, the patient was hospitalized because of anorexia and weakness. Prominent hepatosplenomegaly was noted on examination and scan; the latter showed multiple filling defects. Chest x-ray films revealed a 1.8-em nodule in the left hilar area. Proctoscopy disclosed a metastatie melanoma located 14 cm above the anus. The patient received two courses of polychemotherapy with hydroxyurea, 1,3-bis(2-chloroethyl)-1-nitrosourea, dimethyltriazenoimidazolecarboxamide, and vineristine in July and August; however, hepatosplenomegaly increased. A chest x-ray film in late August
Twelve
showed
days
moderate
later,
left
the
pleural
patient
effusion.
suddenly
developed
COMMUNICATIONS TO THE EDITOR
sharp
435
pain in the left side of the chest and dyspnea; a chest x-ray film disclosed a moderate left pneumothorax visible above the left pleural effusion ( Fig 1 ). A chest tube was inserted but the left lung failed to reexpand. The patient died four days later. DiscusSioN Spntaneous
course
pneumothorax
of
primary
lung
manifestation.
In
pneumothorax
was
same
side
as the
middle-aged
review1
was
secondary
The
majority
than
reported
pneumothorax
tended
known
to occur
to have
pulmonary
had
lesions.
in one-third pneumothorax
of
lungs,5
with
in
frequently
lungs.
sarcomas.
The
patients
peripheral
who
metastatie
pneumothoraces
Wilms’
the
hydrothorax
of the
in younger
the reported occurred with
on
occurred
more
been
multiple
Bilateral
the
and
tumors
have
the
initial
eases.
primary
cases
in an
subject,
by
occurs
with
of such
this
of
unilateral
complicated
of the
late as
commonly
pneumothorax
with
rarely,
tumor,
and
in half
occur
or,
always
primary
Spontaneous
the
recent
almost
men,
or pyrothorax
were
a
may
cancers
developed
cases. Less commonly, carcinoma metastatic to
tumor,2’5
or
with
lympho-
sarcoma.3
The occurrence of spontaneous pneumothorax in our patient is most likely due to pulmonary and pleural involvement by the metastatic melanoma. Kai-Yiu
Yeung,
M.D.,#{176}Hematology-Oncology Veterans Administration
John D. Bonnet,
and
M.D.,
Hematology-Oncology Scott
#{176}Presently at Veterans Reprint requests: Dr. Veterans Administration
Section Center
Section
and
White Clinic Temple, Tex
Administration Center, Hampton, Va. Yeung, Hematolagy-Oncology Section, Hospital, Hampton, Va 23667 REFERENCES
1 Yeung KY, Bonnet JD: Bronchogenic carcinoma u.s spontaneous pneumothorax: Case report of literature. Cancer, to be published 2
l)’Ango
Cl.
lannaccone
a complication T13O S
of
Dines
pulmonary
436
Cortese
J
Am
86:1092-1102, DE,
Spontaneous
of pulmonary
childhood.
Med 3
C:
metastases Roentgenol
in malignant Radium
Ther
neoplasms
COMMUNICATIONS
Brennan
predisposing
MD,
et
al:
to spontaneous
tuNuel
TO THE EDITOR
Malignant
pneumo-
Mayo EA, with
soeiated as
1961 DA,
thorax. 4 Lodmell
presenting with review
pneumothorax
FlGuisx 1. Chest x-ray film ( Sept 6, 1974). A ( top ), Pneumothorax with collapsed lung and hydrothorax in left hemithorax. B (bottom), Enlarged view of left upper pulmonary field, showing left pneurnothorax and outline of ateleetatie lung.
Clin Proc 48:541-544, Capps SC : Spontaneous metastatie
sarcoma:
1973 pneumothorax A report
of
three
ascases.
Radiology 52:88-93, 1949 5 Sherman RS, Brant EE : An x-ray study of spontaneous pneumothorax due to cancer metastases to the lungs. Dis Chest 26:328-337, 1954 6 Spittle MF, Heal J, Harmer C, et al: The association of spontaneous
bone
tumours
pneumothorax
of children.
with
pulmonary
Clin
Radiol
CHEST,
metastases
19:400-403,
71:
in
1968
3, 1977 MARCH,
