Quiz 29 Context:
A 70-year-old female presents as a new patient with a complaint of painful joints, specifically in her shoulders and knees. These symptoms have been present for several years and she has self-medicated with NSAIDS prior to this evaluation. She also reports frequent headaches, fatigue, deteriorating vision, and numbness in her hands.
The patient reports a past medical history significant for hypertension . The family history is significant for lung cancer in her father and a sister. The patient is a retired school teacher; she does not smoke, does not use alcohol, and is married with 3 adult children.
Physical examination reveals a female patient in no distress. Vital signs reveal a temperature of 37.4 degrees Celsius, heart rate 78 bpm, blood pressure 156/92 mmHg. The exam is notable for a diffuse thickening of the soft tissues, coarse facial features and a large furrowed tongue, and a systolic ejection murmur with an S4. The hands are large and moist, and Tinel's and Phalen's signs are positive. Examination of the shoulders and knees reveals signs consistent with osteoarthritis.
The patient's hands, as well as her current and previous footwear, are shown above.
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This history, examination, and data are most consistent with which of the following possibilities as a cause for the symptoms: