History A 69-year-old woman presented to her primary care physician with new-onset dysphonia and increasing shortness of breath, without chest pain. She described her voice as “going in and out” intermittently and reported an occasional cough. She also reported globus sensation without dysphagia. Her medical history included long-standing allergic rhinitis, arthritis, anemia, and gastroesophageal reflux disease. She had a documented history of asthma and had been using the inhaled steroid fluticasone (100 µg/d) since at least 2013, along with an albuterol inhaler as needed for the past 3 years. The patient was a current smoker with a 40-pack-year smoking history, though she had made intermittent attempts to quit. She had undergone yearly lung cancer screening with low-dose CT since 2019. On examination, there was no increased work of breathing, and her lungs were clear to auscultation, with no crackles or wheezing. Echocardiogram was normal. Pulmonary function tests showed severe obstruction: a forced expiratory volume in 1 second (FEV 1 ) of 0.6 L (lower limit of normal, 0.98 L), with
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