What is the recommended physical exam documentation for an elderly patient with a history of atrial fibrillation, on apixaban (direct oral anticoagulant), who presents with a closed head injury, resolving hematoma, and significant ecchymosis on the forehead, without loss of consciousness?

Physical Exam Documentation for Elderly Patient with Closed Head Injury on Apixaban

For an elderly patient on apixaban presenting with closed head injury and forehead hematoma without loss of consciousness, document a comprehensive neurological assessment with specific attention to Glasgow Coma Scale score, pupillary response, focal deficits, and detailed description of the hematoma characteristics, while recognizing this patient requires immediate CT imaging regardless of normal exam findings. 1

Essential Physical Examination Components

Neurological Assessment

• Document Glasgow Coma Scale (GCS) score explicitly - even if 15/15, this must be recorded as patients on anticoagulation with GCS 14-15 have a 1.3% risk of requiring neurosurgical intervention 2
• Pupillary examination - document size, symmetry, and reactivity bilaterally, as asymmetry may indicate evolving intracranial pathology 1
• Mental status - specifically document orientation to person, place, time, and situation; note any confusion, amnesia, or altered consciousness as these are high-risk features requiring extended observation 1
• Cranial nerve examination - assess all 12 cranial nerves with particular attention to visual fields and extraocular movements 3
• Motor examination - document strength in all four extremities using standard 0-5 grading scale to detect focal deficits 1
• Sensory examination - assess for any focal sensory deficits that might indicate intracranial injury 1
• Cerebellar function - document coordination, gait if safe to assess, and balance 3

Hematoma Documentation

• Location - specify exact anatomical location on forehead (e.g., "3 cm above right eyebrow, midpupillary line") 1
• Size - measure and document dimensions in centimeters (length × width) 1
• Characteristics - describe as "resolving hematoma with significant ecchymosis" and note color changes indicating age of injury 1
• Tenderness - document presence and severity of tenderness to palpation 1
• Underlying skull integrity - palpate carefully for step-offs, crepitus, or depression that might indicate skull fracture 1

Cardiovascular Assessment

• Heart rate and rhythm - document rate and note irregularity consistent with atrial fibrillation, as this confirms the indication for anticoagulation 4, 3
• Blood pressure - essential baseline as hypertension increases risk of hemorrhage expansion in anticoagulated patients 4
• Jugular venous pulsations - assess for irregular pulsations characteristic of atrial fibrillation 3
• Heart sounds - document variation in intensity of first heart sound, which is characteristic of atrial fibrillation 3

Additional Critical Documentation

• Signs of increased intracranial pressure - document absence or presence of headache severity, nausea, vomiting, or progressive neurological changes 1
• Evidence of other injuries - examine for additional trauma that may have been missed, particularly in elderly patients who may have fallen 2
• Baseline functional status - document pre-injury cognitive and functional status as elderly patients have worse outcomes after TBI 5, 6

Critical Management Context

Immediate Imaging Requirement

• CT scan is mandatory regardless of normal physical exam - patients on apixaban have a 2.6% risk of intracranial hemorrhage after head trauma, substantially higher than non-anticoagulated patients 1
• The threshold for CT imaging in anticoagulated patients is extremely low and should be obtained for any head trauma, even ground-level falls 1
• Physical examination findings cannot exclude intracranial hemorrhage in anticoagulated patients 1, 2

High-Risk Features Requiring Extended Observation

• Age >80 years (this patient qualifies) 1
• History of loss of consciousness or amnesia (document if present or explicitly state absent) 1
• GCS <15 (document actual score) 1
• Concomitant antiplatelet agents (document all medications) 1

Anticoagulation-Specific Considerations

• Document time of last apixaban dose - this is crucial for determining plasma concentration and need for reversal if intracranial hemorrhage is found 4
• Assess renal function - apixaban clearance depends on renal function, and elderly patients often have renal dysfunction leading to higher drug levels and longer half-lives 4
• Note that apixaban affects standard coagulation tests minimally - PT and aPTT may be normal despite therapeutic anticoagulation, so normal labs do not exclude bleeding risk 4

Common Pitfalls to Avoid

• Never discharge without CT imaging - even with completely normal physical exam, anticoagulated elderly patients require CT after any head trauma 1, 2
• Do not rely on mechanism of injury - ground-level falls in anticoagulated elderly patients carry significant risk of intracranial hemorrhage 1, 2
• Do not assume brief loss of consciousness is benign - elderly anticoagulated patients with GCS 14-15 still have significant risk of deterioration 2
• Document fall risk assessment - this patient needs outpatient referral for fall prevention as recurrent trauma risk is high 1
• Do not discontinue anticoagulation without considering thromboembolic risk - atrial fibrillation carries stroke risk that must be balanced against bleeding risk 4, 1