A 42-year-old woman presents to the clinic with progressive shortness of breath on exertion and a dry cough over the past six months. She also reports progressive tightening of the skin on her hands, forearms, face, and chest over the past year. She initially noticed her fingers becoming puffy before the skin tightened. She describes a three-year history of her fingers turning “white, then blue, then red” when exposed to the cold, which is associated with pain and tingling. She has a history of gastroesophageal reflux disease. Her medications include omeprazole. She does not smoke or drink alcohol. She appears thin and fatigued. Her blood pressure is 135/85 mmHg with a heart rate of 88 bpm, a respiratory rate of 18 breaths per minute, and a temperature of 98.2°F.