There is a clinical picture of PAD; you would want an ABPI to inform your assessment as well. A full limb assessment would be helpful but at this point you have tissue loss and monophasic pulses with query Buerger’s sign in the toe. This should be considered as an urgent referral to vascular service. Urgent referral should ideally be seen within one week, certainly no more than two weeks as you have a window of opportunity. This does not require admission to hospital nor referral to A+E. They should be referred according to local protocol to the multi- disciplinary foot care team and/ or vascular hub. Urgent vascular referral, should be seen within 2 weeks, avoiding A+E referral unless acute infection.