Continuous chest pain from 5 months.

Echocardiogram (Echo): * LVEF ~60% (normal pumping function). * No regional wall motion abnormality. * Normal chamber dimensions. * No significant valve disease. * No clot, vegetation, or pericardial effusion. TMT (Stress Test): * Impression appears to be negative for inducible ischemia. * Achieved 93% of predicted maximum heart rate, which makes the test reasonably adequate. Thus significant obstructive coronary artery disease is less likely The concerning features are: * Persistent chest and rhomboid (upper back) pain for several months. * Dizziness when walking outside. * Heart rate reaching ~125 bpm with activity. * Ongoing weakness. These symptoms may be due to: 1. Musculoskeletal pain (costochondritis, chest wall or rhomboid muscle strain) – common cause of persistent chest and upper back pain. 2. Anxiety/panic-related symptoms – can cause chest discomfort, dizziness, and rapid heart rate. 3. Inappropriate sinus tachycardia or autonomic dysfunction. 4. Anemia, thyroid disorders, vitamin deficiencies (B12, vitamin D), dehydration, etc. 5. Less commonly, rhythm disturbances that may not appear on a resting ECG.

*CBC (hemoglobin) * Thyroid profile (TSH, Free T4) * Vitamin B12 and Vitamin D * Electrolytes * Blood pressure lying and standing * 24-hour Holter monitor if palpitations or rapid heart rate continue * Consider evaluation of the neck/upper back/chest wall if pain is reproducible by movement or pressure Go to the emergency department if: * Chest pain becomes severe or pressure-like. * Pain occurs with exertion and improves with rest. * Fainting occurs. * Severe breathlessness develops. * New ECG changes or elevated troponin are found.