What is the best plan of care for an elderly patient in a Skilled Nursing Facility (SNF) presenting with a severe headache (9/10), normotension (blood pressure in the 120s), and blurry vision?

Immediate Transfer to Emergency Department for Neurological Emergency Evaluation

This patient requires immediate transfer to an acute care facility for emergency evaluation of a potential life-threatening neurological condition, specifically to rule out subarachnoid hemorrhage, stroke, or other intracranial pathology. The combination of severe headache (9/10) with blurry vision represents a neurological emergency regardless of normal blood pressure.

Critical Clinical Reasoning

Why This is NOT a Hypertension Problem

• Blood pressure in the 120s is normotensive and does not explain these symptoms 1
• Research demonstrates that in patients with mild hypertension, there is no association between headache occurrence and blood pressure variation 2
• Among patients presenting with hypertension as a chief complaint without serious associated symptoms, only 2.7% had serious outcomes within 7 days 3
• However, this patient has a serious associated symptom (blurry vision), which changes the risk stratification entirely

Why This IS a Neurological Emergency

• The classic presentation of subarachnoid hemorrhage is sudden-onset severe headache that immediately reaches maximal intensity 1
• Visual disturbances (blurry vision) combined with severe headache are red flag symptoms requiring immediate neurological evaluation 1
• Misdiagnosis or delayed diagnosis of subarachnoid hemorrhage can have grave consequences, including death and severe disability 1

Immediate Actions in SNF Setting

Before Transfer

• Obtain vital signs including orthostatic blood pressures to assess clinical stability 1
• Document exact time of symptom onset and whether headache was sudden or gradual 1
• Assess for additional neurological deficits: altered mental status, focal weakness, speech changes, neck stiffness 1
• Do NOT delay transfer to obtain laboratory studies or imaging in the SNF 1

Transfer Decision Criteria

The patient should be transferred to an acute care facility when clinically unstable or when resident/family goals indicate aggressive interventions should be initiated 1. This patient meets transfer criteria because:

• Severe headache with visual symptoms requires CT imaging and potentially lumbar puncture, which are not available in SNF settings 1
• In patients with acute onset severe headache and new neurological deficit (blurry vision), noncontrast head CT and, if negative, lumbar puncture should be performed to diagnose/exclude subarachnoid hemorrhage 1

Required Emergency Department Workup

• Noncontrast head CT is the mainstay of subarachnoid hemorrhage diagnosis 1
• If CT is negative and clinical suspicion remains high, lumbar puncture with spectrophotometric analysis for xanthochromia is necessary 1
• Digital subtraction angiography may be indicated if SAH is confirmed to identify aneurysm source 1

Common Pitfalls to Avoid

• Do not assume normal blood pressure excludes serious pathology - the blood pressure reading is irrelevant to the neurological emergency at hand 2, 3
• Do not attribute severe headache with vision changes to "stress" or "tension headache" - this combination demands exclusion of life-threatening causes 1
• Do not delay transfer to "observe" the patient - physicians must maintain high awareness for subarachnoid hemorrhage because diagnosis of a sentinel bleed before catastrophic rupture can be lifesaving 1
• Do not perform lumbar puncture in the SNF setting - this requires hospital-based evaluation with appropriate imaging first 1

Documentation Requirements

• Document exact headache characteristics: onset (sudden vs gradual), severity, location, associated symptoms 1
• Record visual symptoms in detail: bilateral vs unilateral, type of blurriness, any visual field defects 1
• Document discussion with patient/family regarding transfer rationale and goals of care 1
• Note time of symptom onset relative to transfer decision 1