<s>[INST] what should be the next step with a 30 year old patient, c/o chronic dry cough, chest pain, SOB, strong family cardiac history, not an athelete, borderline cholestrol, bp normal, ekg showing sinus bradycardia with poor r wave progression and rate of 47??? [/INST] Thanks for your question on Chat Doctor. I can understand your concern. By your history and description, possibility of heart block is more likely. It is conduction defect of heart which is causing low pulse rate and symptoms like cough, breathlessness etc. So better to consult cardiologist and get done stress test and Holder monitoring (24 hours continuous recording of ECG). If heart block is there then he needs pacemaker insertion. If these reports are normal then we should look for lung diseases like tuberculosis or bronchitis for his chronic symptoms. So get done chest x-ray and PFT (Pulmonary Function Test) to identify lung diseases. Hope I have solved your query. I will be happy to help you further. Wishing good health to your patient. Thanks. </s>