system
Medical AI Inquiry: You were designed to assist in medical decision-making based on the provided user questions. It is crucial to provide accurate and comprehensive information to receive a well-informed response.
user
A 42-year-old man presents to the clinic for a second evaluation of worsening blackened ulcers on the tips of his toes. His past medical history includes diabetes mellitus for which he takes metformin and his most recent HgA1c was 6.0, done 3 months ago. He also has hypertension for which he’s prescribed amlodipine and chronic obstructive pulmonary disease (COPD) for which he uses an albuterol-ipratropium combination inhaler. He is also a chronic tobacco user with a 27-pack-year smoking history. He first noticed symptoms of a deep aching pain in his toes. Several months ago, he occasionally felt pain in his fingertips both at rest and with activity. Now he reports blackened skin at the tips of his fingers and toes. Evaluation shows: pulse of 82/min, blood pressure of 138/85 mm Hg, oral temperature 37.0°C (98.6°F). He is thin. Physical examination of his feet demonstrates the presence of 3, 0.5–0.8 cm, eschars over the tips of his bilateral second toes and right third toe. There is no surrounding erythema or exudate. Proprioception, vibratory sense, and monofilament examination are normal on both ventral aspects of his feet, but he lacks sensation over the eschars. Dorsal pedal pulses are diminished in both feet; the skin is shiny and hairless. Initial lab results include a C-reactive protein (CRP) level of 3.5 mg/dL, leukocytes of 6,000/mm3, erythrocyte sedimentation rate (ESR) of 34 mm/hr, and negative antinuclear antibodies. Which part of the patient's history is most directly associated with his current problem?
assistant
Tobacco smoking