Jane Deglutinato is a 50-year-old female with a 4-month history of progressive dysphagia, symptomatic heartburn and regurgitation that has not responded to the use of regular non-prescription oral antacid medications. She has also noticed some general joint discomfort and painful swelling of her fingers with occasional pain and discoloration of the fingertips. She also reports having lost approximately 9 lbs of weight over that period of time related to a reduction in her appetite. Her bowel movements continue to be formed with no evidence of blood or fatty stool. On examination, her vitals are within normal limits and she is afebrile. Her weight is 55 kg. You notice that she has some tightening of the skin around her mouth as well as her fingers and toes, with pitting and some ulceration of the fingertips on both hands and toes of both feet. You also note several telangiectasias over her chest and upper torso. Cardiac and respiratory as well as abdominal examinations are unremarkable.