FMCSA DOT Physical ME Test Annie

anxiolytics and sedatives:

Benzodiazepines - D/C OK: hyponotics if short-acting (half life < 5h) and short period (less 2 weeks) IF benzo - wait at least 7 half lifes out of system

Blood glucose levels considered safe for commercial driving?

Between 100-400.

Disqualifying cardiac factors:

CHD symptoms: ischemic ECG change at rest, EF < 40%, inability to complete exercise TT angina at rest or with exertion, syncope, poor medication tolerance Hypertrophic, dilated, or restrictive cardiomyopathy Pulmonary HTN Warfarin tx - not monitoring INR Unrepaired vascular, CV, valvular, and congenital conds. Implantable defibrillator

Other conditions to evaluate if they have a dx of HTN?

CHD, heart failure, left ventricular hypertrophy, stroke/transient ischemic attack, peripheral artery disease, retinopathy, nephropathy, and other target organ damage.

If #4 and #5 are a "no?" (is the individual compliant with blood glucose self monitoring)

Call TC and get more info about why.

Certifying pt with confirmed OSA?

Can certify, using frequent recert, once adequately treated.

If the TC does not have 3 months prior of BG monitoring, what do you do?

Can give them a 3 month card. Once the TC reviews these records, the TC then fills out a new 5870 and then the ME may issue a 12 month card.

Vision exam:

Central vision acuity: Snellen Visual field: 70 degrees confrontation Color Examine eye: pupillary equality, reaction to light & accomodation, ocular motility, muscle imbalance, EOM, nystagmus, and exophthalmos - instead of fundoscopic exam: ask retinopathy, cataracts, aphakia, glacuoma, mac degen.

Hx of DVT: Certify If: WP: Card time?

Certify if no residual DVT WP: 1 month if on Warfarin and meets anticoagulant guidelines. No WP if anticoagulated on heparin (bc don't need to wait to get INR right) -Must be anticoagulated for a minimum of 3 months (preferably 6) post DVT. Annual recert

A fib (with low risk strone) cert:

Certify: yes WP: no Recert: annual Use validated stroke risk screening: CHADVASC

How long do you have to submit driver determination online after doing exam?

Close of next calendar business day.

Acute infectious diseases:

Common colds, flu, acute bronchitis, etc. No antihistamines or antitussives can cause sedation and shold not drive 12 hours

Orthostatic hypotension?

Common complication with diabetics with autonomic dysfunction

If BMI is 33-39 and they have 3/11 risk factors for OSA?

Conditional certificate and refer for sleep study

While performing the examination, for any initial BP that is ______ or higher you must:

Confirm BP greater than 139/89 with a second measurement taken later during the exam.

Don't certify until etiology is _______, and _____ is shown to be _____, ______, and _____.

Confirmed, treatment, safe, effective, stable.

Other questions to ask if dx of HTN?

Contact information for the treating provider and a medical release form? •Symptoms related to or caused by high BP? •Limitations resulting from the disease or treatment? •Lifestyle risk factors, particularly modifiable behaviors and conditions (e.g., smoking, obesity, and/or lack of exercise)? •Uncontrolled hypertension while using three or more antihypertensive medications at close to maximum dosages? If the response is "yes," an evaluation for secondary hypertension may be appropriate.

CHD risk equivalents & how long to certify?

DM, PVD, Framingham > 20%, >45 yo with multiple risk factors --> 1 year certification and add tests based on sx.

Idiopathic dilated cardiomyopathy and CHF:

DO NOT CERTIFY: Sympt. Asympt: ventricular arrhythmias present, LVEF < 50% Asymp: no arrhy. but LVEF < 40% YES: IF asympt, no vent arrhythmias, LVEF < 40-50% Recert: annual

What if they are anticoagulated due to a prior stroke or TIA?

DO NOT certify

2 spontaneous pneumos on same side and not treated?

DQ

ICDs? (implantable cardiac defibrillators)

DQ

Labyrinthine fistula and non-functioning labyrinth?

DQ

Labyrinthine fistula or nonfunctioning labyrinth?

DQ

Menieres?

DQ

Narcolepsy?

DQ

Uncontrolled vertigo?

DQ

Narcolepsy:

DQ Requires letter from provider describing monitoring, degree of tolerance Wait 6 weeks for stablizaiton, max 1 year

Uncontrolled vertigo? Waiting period?

DQ. WP is 2 months sx free.

Congenital Heart Disease

Diagnosis and severity ECHO, ETT

Sustained V-tach > 15 seconds?

Disqualifying

Meds with underlying conditions:

Disuliram (antabuse) = alcoholism DQ Carbidopa levodopa (Simemet) = Parkinsons Modafain (Provigil) = narcolepsy

Severe TBI?

Do not certify if LOC>24 hours, any surgery with dural penetration

Syncope?

Do not certify until etiology is confirmed, treated, and tx is adequate, safe, stable. If they've had more than one episode of syncope, be cautious. Don't certify if syncope is sx of other dz, unless treated fort hat dz. Don't certify if high risk for sycnope, even if treated but still at risk, eg. ICDs

History questions to ask diabetic drivers?

Do you routinely measure your blood glucose? Use OTC meds/supplements/incretin mimetics? Hx of fainting/dizziness/LOC? Hx of hypoglycemic reaction with seizure, LOC, needing someone else to give you sugary food, or "impaired cognitive function that occured without warning"? If yes to last qustion, 1 or more than 1 episode in last 12 months? 2 or more than 2 in last 5 years?

Abnormal urinalysis?

Don't certify until dx of kidney dz is confirmed and treatment is stable. Okay to time limit and f/u with PCP for Cr/GFR.

Headaches?

Don't certify until etiology confirmed and no impairing sx

HgbA1C?

Don't look at it in isolation. Maybe it's a 10 now, but maybe it used to be a 14. Great! Or maybe it's a 10 now, but a year ago it was a 7! Warning sign.

DQ respiratory sx

Dyspnea at rest, cough syncope, dizziness, hypotension, hypoxic

Secondary HTN

EX: Pheochromocytoma, primary aldosteronism, renovascular dx, unilateral parenchymal dx If surgical interventions: min WP 3 months MAX cert: 1-year post Rec certification if BP < 140/90

Glucosuria?

Either uncontrolled diabetic OR on a medication that causes sugar to spill into urine (SGLT2 meds: jardiance/invokana/farxiga--the "flozins")

If PFTs demonstrate FEV1 less than _____, FVC less than _____, or FEV1/FVC ratio less than _____, obtain _____?

FEV1: 65 FVC: 60 FEV1/FVC: 65 ABGs

Recommendation for driver on an incretin mimetic?

FMCSA recommends that a driver taking an incretin mimetic provide a written statement from the treating health care professional. The written statement should: •Describe driver tolerance to the medication. •Indicate how frequently the driver is monitored for adequate blood glucose control. •Include efficacy of treatment.

V tach:

For sustained VT > 15 seconds DO NOT cert if EF < 40% If EF > 40% and asymp, certify after 1 month WP Recert: annually

What is the vision waiver program?

From the 90s. Still need to present original letter and copy of recent eye exam. Grandfathered in.

What if spilling 3+ glucose but no dx of DM?

Get a fingerstick BG. If shows DM, then what? Several options. Can DQ and have them f/u with PCP. Can give a 3 month and have them f/u with PCP. If have 6 weeks left on card, can do determination pending and f/u with PCP. That way, don't have to do a new exam when they return.

OSA Risk Factors

HTN BMI (33-39, severe >40) Neck Size (>17 cm men, 15.5 cm women) DM Loud snoring Witnessed apnea Sleepiness while awake Single vehicle crash Hypothyroid Micrognathia/Retrognathia Older than 42 Male or postmenopausal female Mallampati score of 3 or 4 CAD Arrhythmias Hx of stroke

SPEs are for?

Hand, leg, foot, arm fixed deficit. No shoulder/hip/spines. Distal extremities only. No progressive deficits. No fixable deficits. Apply through FMCSA and renew every 2 years. Must be otherwise medically qualified; like with the exemptions.

Do not certify AAA if growth is:

Has increased more than 0.5 cm during a 6 month period, regardless of size.

What exemption programs are there currently?

Hearing, vision, and seizure.

6 METS means:

Heavy and very heavy work requires greater than 6 METs and includes carrying heavy objects (>50 lbs) and climbing stairs rapidly.

What testing MUST be done for the exam?

Height, weight, vision, hearing, BP, pulse, urinalysis.

HgbA1C of 10?

Hemoglobin A1c (HbA1c) greater than 10% is an indicator of poor blood glucose control. It is recommended that you obtain further evaluation or monitor the driver more frequently to determine if the disease process interferes with medical fitness for duty and safe driving.

PFTs indications:

Hx of specific lung dx, symptoms of SOB, cough, chest tightness, wheezing, smoking in drivers 35 or older (FEV1, FVC, FEV1/FVC ratio) Screening pulse ox and or ABG inidicated if FEV1 <65% If pulse ox <92% must have ABGs

What should a driver who is on 2 DM meds make you concerned about?

Hypoglycemia

Asthma d/c:

IF not stable, uncontrolled s/s Signif pulmonary function impairmental (FEV1 < 65% and PO2 < 65mm)

WP for bacterial/viral meningitis?

If bacterial/viral and no seizures: must wait 1 year seizure free and off meds. If bacterial with early seizures: 5 years seizure free and off meds If viral with seizures: 10 years seizure free and off meds.

Certifying epilepsy?

If epilepsy dx: driver must be seizure-free for 8 years, on or off meds IF taking anti-sz meds: the plan for meds should be stable for 2 YEARS

Seizure exemption program

If on seizure meds, option to get certified. Notice for public comment for 30 days, then agency decides. Epilepsy: Seizure free for 8 years (on or off meds) Meds stable for 2 years (no changes at all) Single unprovoked: seizure free for 4 years (on or off meds) Single provoked

WP after need for rescue glucose?

If previous dx of DM: 1 month If no previous dx of DM: 2 months

If questions #2 and 3 on the form are "No"? (no 3 months of self monitoring records)

If you feel comfortable, you can issue a 3 month card for them to get these records. (it allows this directly on the 5870)

Risks of HTN - between ages ____, the risk for cardiovascular dz _______ for every _____ increase in systolic or _____ increase in diastolic

In individuals ranging from 40 to 89 years of age, for every 20 mm Hg systolic or 10 mm Hg diastolic increase in BP, there is a doubling of mortality from both ischemic heart disease and stroke. The relationship between BP and risk of a CVD event is continuous, consistent, and independent of other risk factors. Both elevated systolic and diastolic BP are risk factors for coronary heart disease (CHD)

Pulmonary HTN:

Increase risk of incapacitation and sudden death 2nd ary pulm HTN = Eisenmenger's synd. Max cert = 1 year

Sulfonylurea with what other oral med increases risk of hypoglycemia? What is required if a driver is on both?

Incretin mimetics (GLP-1s). Guidance is for 1 year cert. Recommendation is for a written statement from TC on how individual is followed and if there are any complications. This is true for incretin mimetics or any potentially impairing drug.

What is required for the insulin self monitoring?

It must be electronically downloaded with recorded date and times. Can't be handwritten. A printout must be provided to the TC at the time of the eval.

Thoracic aneurysm size okay to certify? WP post surgical repair? Certification thereafter?

Less than 3.5cm and asymptomatic NOT to certify if > 3.5cm Wait 3 months and cleared by a specialist Annual

CNS stimulants

Max= 1 year do not if underlying cond (narcolepsy) or SE Dextroamphetamines, methyphenidate, pemoline

When you request an eval for a driver, what is helpful to include with your request?

Medical Examination Report form description of the driver role and medical standards.

Headaches of concern:

Migraine, cluster, tension, post-trauma, substance-associated, withdrawal, cranial neuralgias, atypical facial pain

Mild-Moderate TBI

Mild: <30 mins LOC, no dural penetration Moderate: <24 hours LOC, no dural penetration 2 year WP 5 years if early seizure

Pneumothorax:

Must ensure recovery of CXR If air in pleural space or mediastinium, added time away Certify if asymptomatic, no underlying lung dx NO: hx 2+ spontaneous pneumo. if no successful surgical procedure to precent recurrence, rest hypothermia, chronic RF

Intermit claudication:

NO If having pain at rest YES: if at least 3 months post surgery with relief of s/s WAITING: 3 months after REcert: annual

Post MI guidelines:

NO if recurrent angina, post-MI EF <40%, abnormal ETT, ischemic changes on ECG, poor tolerance of current CV meds YES if at lesast 2 months post-MI, cleared by cardio, no angina, EF < 40%, tolerance of CV meds WAITING: 2 MONTHS RECERT: annual DX: diennial ETT with imaging stress test

If can't determine colors?

Need further testing.

What to do if proteinuria?

Nephrologist consult

Presence of what DM complications should you probably DQ?

Neuropathy, retinopathy, nephropathy, CVD.

If you have audio-metric testing in the office, can you test them if they use a hearing aid?

No

Is there a requirement for ME to review beyond the 5870?

No

Varicose veins?

No WP 2 year cert

Pulmonary Tb

No certif when contagious, not meeting PFTs, chronic TB, noncompliance with meds, not complete streptomycin, residual 8th CN with effects MAY: not contagious, stroptomycin therapy complete (not affecting hearing or balacne), compliant with antitubercular (no SE that interfere with safe driving)

Certifying aseptic meningitis?

No increased risk of seizures; may certify once resolved

Monocular vision exemption:

No longer exemption If driver know they have monoc. Vision, get form & go to license OP. within 45 days before the CME examination Must keep form 5871 on file for 3 years (does not need to be sent to FMCSA)

What happened to the Diabetes exemption?

No longer needed. They can be qualified like everyone else.

If driver has cardiovascular disease, what must be true about them in order to certify?

No physical limitations No residual sx No meds likely to impair Normal resting/stress ECG (if abnormal, get additional eval/testing) Get info from treating provider!

Nitroglycerine use - DQ?

No, but need cardiologist letter certifying angina is stable.

Does corrective glasses include cataract implant?

No.

Exemption for contact monovision?

No.

Is hyperglycemia (>400) likely to cause impairment?

No.

Does determination pending require a new exam?

No. A short medical certificate does, but a DP does not.

Is there a requirement for annual eye exams?

No. If exam was within 18 months and no prior problems, probably fine. If 5 years since last one, should probably have them get one before certifying.

Are you required to accept the medical insulin form? What are you supposed to decide

No. Must decide: -Maintaining stable insulin regimen? -Properly controlled DM? ("Non-compliant" or "No show" on medical records from TC demonstrates not following advice of TC) -Permanent DQ if severe prolif or non-profil retinopathy.

Is monocular vision okay?

No. Need to have 20/40 in BOTH eyes. No corrective contacts that make one eye see far/one near. No telescopic lenses.

Is there a *regulation* about specific BP?

No. Only guidance.

Is the medical certification limited to their current employer?

No. They are allowed to switch employers that might require more strenuous tasks/different schedule, etc.

Can a medical examiner grant a waiver?

No. They have to go through the online FMCSA processes.

Are DM exemptions/waivers still valid?

No. They must use the new form.

Guidance on HgbA1c?

None.

WP for people on incretin mimetics, eg. Byetta?

None.

Required WP after Lasik procedure?

None. But do recheck visual acuity.

Provigil (modafinil)?

Not DQ but be cautious.

COPD d/c:

Not certified if hypoexmia at rest, chronic resp failure, hisotyr of continued cough with cough synceope If FEV1<65%, ABG should be measured

How long for stage 3?

Not certified until 140/90 or less, then every 6 months thereafter. (unique)

Need medical records for IDDM along with 5870?

Not required, but definitely a good idea.

If they've been issued a 3 month card, and they come back and their BP is still greater than 140/90, recommend:

Not to certify

If they have a history of Stage 3 HTN adn their BP is greater than 140>90, recommend:

Not to certify (later on says case by case basis can do 3 month card)

Renal disease do not certify:

On Dialysis Stage 5 no renal replacement Excludes renal transpalnts All drivers with risks for CKD should have Cr with calculated GFR

Hearing standards?

Only need to meet in 1 ear. Whisper at <5 feet or audiometry standards better in one ear than 40 DB at 500/1000/2000 hz

Stage 1 HTN?

Over 140/90. Systolic: 140-159 Diastolic: 90-99

Stage 2 HTN?

Over 160/100.

Stage 3 HTN?

Over 180/110.

Vision exam includes?

PERRLA, EOMs, confrontation, nystagmus, eval for exopthalmos

On ABGs, DQ if PaO2 is less than ___ or PaCO2 greater than ___?

PaO2: less than 65 PaCO2: greater than 45

Get a Cr/GFR for drivers with:

Personal hx of CKD Age over 65 DM HTN Proteinuria

What to evaluate with peripheral neuropathy in diabetics?

Position sense in toes and feeling in feet.

What is REQUIRED to record/document for every positive documented disease/medication on the driver form?

Regulations — You must document discussion with the driver about •Any affirmative history, including if available: -Onset date, diagnosis. -Medication(s), dose, and frequency. -Any current limitation(s). •Potential negative effects of medication use, including over-the-counter medications, while driving. •Any abnormal finding(s), noting: -Effect on driver ability to operate a CMV safely. -Necessary steps to correct the condition as soon as possible, particularly if the condition, if neglected, could result in more serious illness that might affect driving. •Any additional medical tests and evaluation

Find a neuro deficit on exam?

Requires a neuro consult and annual neuro evals thereafter

Do not certify after MI IF:

Rest angina or change in angina pattern within 3 months of examination. Ischemic changes on rest electrocardiogram (ECG). Intolerance to cardiovascular ther

Vision history includes?

Retinopathy, cataracts, aphakia, glaucoma, macular degeneration.

Valvular dz If severe: If moderate or mild but symptomatic: If mild and not symptomatic:

Severe: DQ Moderate mild with sx: DQ Mild and no sx: can certify but follow on a regular basis.

What type of retinopathy gets DQs?

Severe: Unstable proliferative OR non-proliferative.

Stable or unstable - sliding scale insulin?

Stable as long as 3 month records show that BG has been stable.

Stable or unstable - same dose of insulin for 6 months?

Stable.

Recommendations for CKD

Stage 1-2 (GFR 90-30): Bring Cr and GFR to exam; 2 year cert for stage 1-2, 1 year cert for Stage 3 (below 60): annual Stage 4 (GFR 15-30): 6 month cert: if EKG WNL, BP < 140/90 3 month cert: if EKG WNL, BP 140-180/90-110 Stage 5 - DQ

Insulin TX: 2-step certification process

Step 1) TC eval with use of ITDM Assessment for MCSA-5870 valid for 45 days Step 2) CME exam May cert: 12 months Disq: unstable insulin regimen, DM not controlled OR severe retinopathy

Convert ISO to ANSI

Subtract 14 dB from ISO for 500Hz Subtract 10 dB from ISO for 1000 Hz SUbtract 8.5 dB from ISO for 2000 Hz

DO NOT recert ventricular arrythmias IF:

Sustained VT NSVT, LVEF<40 HOCM, long QT, brugada

Does the driver need a new exam after sustaining an injury?

That is up to the employer.

What form for the new Diabetes Insulin Standards and who fills it out?

The Insulin-Treated DM Form, filled out by treating clinician.

Who is required to prescribe and manage the insulin?

The TC who fills out the form.

What is the date for the certificate expiration?

The date of determination, NOT necessarily of the exam.

If you do determination pending, what do you put as the expiration date?

The date they come back with whatever documentation you needed.

If a diabetic with an amputation, then what?

They can fill out a SPE.

Do not certify SVTs IF:

They cause LOC, compromised cerebral function, sudden death requiring resus

What is required if the driver on insulin has a severe hypoglycemic episode?

They must contact the TC asap and be re-evaluated with a new 5870. They do not have to go to the medical examiner until next exam. They do not have to tell their employer. BUT you can encourage your clients to come back for re-evaluation.

Audiometry requirements:

Three pitches only: 500 Hz 1000 2000 If hearing aids - need audiologist to do LOWER the decibels the better (35 D better 45) The average of only 1 year = less 40 = PASS

What is the role of the examiner with medical exemptions?

To determine if the driver is "otherwise qualified" besides the one issue that they will need an exemption for.

True or false: The examiner should advise the hearing aid wearer to carry a spare set of batteries.

True.

Chronic thrombotic dz? Recert time?

Understand why recurrent clots. Is it controlled? Up to 2 years re-cert (unique) unless sx of uncontrolled dz.

Schizo:

WP - 6 months if brief reactive psychoiss or schizophreniform ds 1 year sympt free if any other psychotic disorder MAX = 1 year

Ventricular arrythmias WP Recert?

WP 1 mos (unique) Annual recert IF Asx and cardiac clearance

Bipolar Mood disorder

WP: 6 months - if non-psychotic MD with no SI 1 year - severe depress, SI, manic MAX 1 year

PCI WP? Max cert? Certify if?

WP: 1 week (also unique) Max cert: start with 6 months, then 1 year Certify if: -Asx, tolerates meds, no injury to vascular access site -No ischemic ECG changes -Cleared by specialist -Biennial ETT *Driver should have ETT 3-6 months post PCI and bring results to 6 mon follow-up

Heart Transplant WP? Cert if?

WP: 1 year (unique) Certify for 6 months (unique) IF -Asx, stable on meds -No signs of rejection -Meets all other criteria

CABG WP? Max cert? Certify if:

WP: 3 months Max cert: 1 year IF -Asx, Tolerates meds w/o orthostatic sx, LVEF>40 -Approved by cardiologist -Healed sternum Recert: annual -ETT every 2 years post-bypass (unique)

Pulmonary embolism WP? Recert?

WP: 3 months with no PE On appropriate tx Meets anticoag guidelines Annual recert

MDD (major depressive disorder)

WP: 6 months if non-psycho MD without SI 12 months: if severe MDD, SI attempt, maniac MAX CERT: 1 year

Questions to ask treating physician of driver who had a hypoglycemic episode

Was the episode unique and unlikely to recur OR is the driver non-compliant/has the doctor needed to make frequent/recent medication changes, etc?

Resting tachycardia...

What happens with exertion?

The fundamental question in certifying a driver:

Whether the driver has a CARDIOVASCULAR DISEASE that increases the risk of sudden death or incapacitation and creates a danger to the safety and health of the driver, as well as the public sharing the road

Do you use the systolic or diastolic to guide your decision?

Whichever is higher.

A fib (with risk of stroke decreased by anticoags)

YES- if adequately anticoaged for a least ONE MONTH: warfarin monitored at least monthly with INR; rate and rhythm control deemed adequate WP: one month for therapeutic tx Recert: annual DX: proof of monthyl monitorign of INR

Is dialysis disqualifying?

Yes

Okay to examine drivers from Canada and Mexico?

Yes

Whisper test okay for hearing?

Yes

Document every abnormality?

Yes, and then just write in comments, "not likely to interfere."

Meniere's disease - DQ?

Yes, if active dx due to risk of incapacitation from vertigo spells. If in remission, no episodes for 10 years, probably fine.

Exemption for natural monovision?

Yes, if one is is >20/40, can apply.

Are hearing aids allowed for the whisper test?

Yes.

Who fills out SPE?

You do the entire med exam, then they go to a rehab facility for an orthopedist or physiatrist to fill out rest.

Even if a disease requires no WP, what should you still determine before certifying?

You should not certify the driver until the treatment has been shown to be adequate/effective, safe, and stable.

Lithium:

no WP MH specialist and drug montioring NO NIGHT DRIVING

SAP:

suspected alcholism or drug abuse warrants completion of SAP (substance abuse prof) evalaution, and if indivated, drug rehab program If SAP provides doc allowing driver to return to work and does not dx acoholism, may return to driving

REGULATION: On history, for cardiovascular, you must ask about:

•Chest pain? •Chest pressure or ache with exertion? •Pain, pressure, or dyspnea at rest or with exertion? •Recurrent and/or severe palpitations? •Pre-syncope (dizziness, light-headedness) or true syncope (loss of consciousness)? •Medical therapy that requires monitoring?

Severe hypoglycemic episode as defined on TC form 5870 for IDDM drivers:

"FMCSA defines a severe hypoglycemic episode as one that requires the assistance of others, or results in loss of consciousness, seizure, or coma." Leaves out impaired cognition and adds in coma.

What do you document if driver stops exam?

"Incomplete exam"

What does the new insulin form require?

-Annual med exams -The form must be filled out by TC within 45 days of med exam -TC must determine if medically qualified and free of complications

Vision acuity requirements?

20/40 in each eye and together.

Which CNS tumors do not certify?

Any malignant, whether primary or metastatic Benign nervous system tumors

What optional testing may be done?

BMI, audiometry, PFTs, ECHO, EKG, sleep study, CT scan, etc, based on H&P and your determination. CAUTION: If you require these, you CANNOT be the one ordering or paying. Must be employer or driver's private health insurance or private pay.

Why do we worry about nephropathy?

Can cause cognitive impairment when in hot environments and dehydrated.

OSA:

Goal: identify those with mod to severe OSA = (apnea-hypopnea index AHI) > 15

Pre-diabetic cert timeframe?

If concerned may progress to DM, 6 mos or 1 year.

Mitral valve regurgitation

Mild: annual exam if asymp. (no annual ECHO) Mod: annual exam if asymp, NEED annual ECHO Severe: annual cert. if asymp, NEED ECHO Q6-12 months or if at least 3 months post-repair, asymp, and cleared NO! if sympt, unable > 6 METS on bruce protocol, ruptured chordae or leaflet, A fib, LV dysf, thromboembolism

Epilepsy?

Must DQ if med hx of epilepsy or current dx of epilepsy

If have DM, not on insulin, but not controlled, qualified?

No.

When checking pulse, you must note:

Rate, rhythm, and strength.

What is the only end-organ damage complication due to DM that is DQ?

Severe proliferative retinopathy or nonproliferative retinopathy.

Potential S/E of eye drops/meds that could cause problems?

Stinging, blurring, decreased night vision, sensitivity to glare, headache, allergic reaction

If they can't feel their feet at all...

Think carefully about if you want to certify or not.

Meds need monitoring:

Warfarin Theophylline Lithium

Personality DZ

certification 1 year if: complies with tx No alcohol or drug dependency

Antipscyhotics -

tx: schizo, psychotic mood dx, personaliaty, nausea, chronic pain MAX cert = 1 year Any new antipsychotic must be eval within 1 month

REGULATION: On physical exam, for cardiovascular portion, you must examine for:

•Murmurs, extra heart sounds, or arrhythmias? •An enlarged heart? •Abnormal pulse and amplitude, carotid or arterial bruits, or varicose veins?

Risk for HTN in drivers based on years of driving experience:

-29% in drivers with fewer than 10 years of driving experience -32% in drivers with 10-20 years of experience -39% in drivers with more than 20 years of driving experience. As the years of experience rise, part of the increase in hypertension may relate to accompanying aging, increase in body mass, or decline in physical activity.

If BMI is over 40, consideration for sleep study?

-3 month certificate -Refer for sleep study -DQ immediately if hx of fatigue/sleepy while driving, hx of sleep related crash, or non-compliant with OSA tx

When recommend NOT to certify driver with DM?

-A severe hypoglycemic reaction in the last 12 months or 2 within the last 5 years. -Loss of position sense -Loss of pedal sense -Orthostatic hypotension -Resting tachy -Peripheral neuropathy -Proliferative retinopathy

Types of cardiomyopathy needing DQ?

-HOCM -Restrictive -Idiopathic dilated with CHF -Asx BUT ventricular arrythmias and LVEF <50 -Asx BUT no ventricular arrythmias BUT LVEF <40

What is required to pass their ECHO?

-LVEF>40% -No pulmonary HTN.

To certify multiple sclerosis, must have:

-No signs of relapse or progression -Tolerates meds well -Good vision -Completed neuropsychological battery of testing (normal based on age/education) -Good control over or no sign of mood disorder -Good motor function and mobility -No excess fatigability -Periodic fluctuations in motor performance with stressors

What are the 13 physical qualifications for drivers?

1 + 2. No loss/impairment of foot/leg/hand/arm. 3. No IDDM (new waiver) 4. No dx of heart dz that might cause syncope, SOB, collapse, or CHF 5. No respiratory dysfunction likely to interfere 6. No HTN likely to interfere 7. No hx or dx of MSK dz likely to interfere 8. No hx of epilepsy or dz causing LOC 9. No mental/psych dz likely to interfere 10. Distance vision of 20/40 in each eye and together, 70 degrees horizontal field, and ability to recognize red/green/yellow 11. Whisper at 5 feet in BETTER ear or no average HL in better ear>40 DBs at 500,1000,and 2000 hz 12. No schedule 1, amphetamine, narcotic, habit forming drugs except when prescribed by someone who says it will not affect ability to operate CMV 13. No dx of alcoholism

Pacemaker WP Recert if

1 month WP if sinus node or AV block 3 month WP if neurocardiogenic syncope or hypersensitive carotid sinus with syncope 1 year recert IF They have documentation of functional pacemaker and documentation of routine checks

WP for anticoagulants?

1 month stabilized

How long a certification is given for vision/diabetes exemption programs?

1 year

Recommended certification for DM even if not IDDM?

1 year

Syncope recert IF:

1 year IF -Treated for dz -Asx -Tolerates meds -Low risk for recurrence -Clearance

Acute sz from structural brain injury: WP

1 year SZ free and off anticonvulsants: mild insult without early sez, stroke w/o seizure risk 2 year SZ free and off anticonv: moderate insult w/o early seizure or mild WITH early seizures 5 years SZ free and off anticonvulstants: if moderate insult with early sz, stroke with risk of seziures MAX cert: 1 year

TIA?

1 year TIA free WP

Stroke? (ischemic or hemorrhagic)

1 year WP after stroke with no risk for seizures (aka cerebellum or brainstem) and/or mild insult 5 year WP after cortical, subcortical strokes After these WP, may certify for 1 year if -Normal neuro, neuro-ophth, and neuro-psych exams -Residual deficits that don't interfere with CMV driving -Clearance from CMV knowleadgable specialist

Cystic fibrosis:

1 year certification period NO: hypoxemia at rest, chronic resp failure, cough with syncope, unstable ABG if FEV1 <65%

Recommended time for card for diabetics?

1 year, but more frequently if more frequent exams are required to monitor progression of condition

Max certification for warfarin? What must they bring with them?

1 year. Copy of monthly INR results. Need to have at least monthly monitoring. If other anticoag than Warfarin, clinical judgment.

How long a card if stage 1?

1 year. Needs to be less than stage 1 at next visit. If still Stage 1 after a year, 3 month card.

What is "acceptable risk?"

1% annual risk of sudden incapacitation. If the driver is at increased risk compared to the general population, than they shouldn't be operating a CMV.

2 reasons for not medically qualified?

1) Disease/condition that temporarily or permanently DQs them OR 2) Haven't fulfilled appropriate waiting period, eg. 1 year

4 possible options for determinations for medical exam?

1) Qualified 2) Not qualified 3) Determination pending 4) Incomplete

What to do if current med certificate expires tomorrow, but you need their HgbA1C, etc?

1) You can issue a short term certificate AND do determination pending but will need to repeat the exam 2) DQ and do a determination pending if you do not think driver is safe to be on the road in the meantime before you get the info

When was the revised DM standard effective?

11/19/18

Antidepressants:

1st gen: interfere with driving (tricyclics) D/C 2nd gen: fewer SE MAX cert: 1 year No WP

How many months sx free if have BPPV or peripheral vestibulopathy?

2

MI WP? Max cert? Requirements to cert after MI Tests after MI?

2 months (UNIQUE - odd bc everything else in cardiovascular is 3 months) 1 year max cert IF: -Asx -Tolerates meds -ETT, LVEF, ECG. -ETT WNL -LVEF>40 -No ECG ischemic changes -ETT every 2 years -Clearance from cardiovascular specalist (if PCP, ask to see records)

Vertigo and dizziness WP

2 months asymptomatic

WP for BPPV or acute/chronic peripheral vestibulopathy?

2 months symptom free.

How many physical exams by TC are drivers with DM required to have per year?

2 per year

WP post surgical removal of a tumor with no seizures?

2 year if benign supratentorial or spinal. 1 year for all others. After that, may certify if stable, nonprogressive deficit or no deficit No tumors on imaging Max: 1 year

TBI WP:

2 year sz free on and off anticonvulsants for mod TBI without early sz or mild Ti with early sz 5 years sz free and off anticonv for mod TBI with early sz

Hint: With cardiovascular disease tends to be _____ month WP post surgery and _______ re-certification

3 month WP Annual recertification

If already treated for BP (on antihypertensive meds) and they have stage 1 HTN, recommend:

3 month cert

If already treated for BP (on antihypertensive meds) and they have stage 2 HTN, recommend:

3 month cert

PVD: WP post surgical repair? Recertification period? When to DQ?

3 months post surgical repair if relief of sx Recertify annually DQ if resting pain

WP for AAA surgery?

3 months post-surgery and must be cleared by a specialist. Annual certification thereafter.

Angina WP? Max cert? Certify if:

3 months stable 1 year cert IF: -Stable -Asx -Tolerates meds -Eval by cardiac specialist -Biennial ETT

Waiting period after surgical correction for secondary hypertension?

3 months.

How long a card if stage 2?

3 months. If TC wants to lower slowly, may extend for another 3 months. Once below stage 1, annually.

Valve replacement WP? Recert?

3 mos WP Recert for 1 year IF -2D ECHO after procedure and prior to D/C (unique) -Cleared by cardiologist -Mechanical valve: appropriate anticoag (unique) 4 week WP if percutaneous balloon valvotomy (unique) Annual card eval: H&P, ECHO, CXR (unique)

Single unprovoked seizure?

5 years off anticonvulsants and seizure free and cleared by neurologist Max: 1 year A 2nd unprovoked seizure would = hx epilepsy

CDC defines loading & unloading a truck as how many METS?

6

ECT therapy:

6 month waiting period after ECT

If pulse ox is less than ____, obtain ___?

92 %. ABGs

When to certify with dx of AAA and for how long?

<4.0 cm: Must be asx - annual 4.0-5.0 cm: Must be asx and have a vascular surgeon clearance - annual >5.5 cm (men) or 5.0 cm (women) or any size symptomatic or not cleared by a vascular surgeon: Do not certify.

What is required to pass their ETT (exercise stress test)?

>6 METS HR>85% (unless on a beta blocker) Systolic increased by 20 mm without angina No significant ST segment elevation If driver can't pass ETT on a treadmill, they probably shouldn't be driving.

SVT (A-fib, a-flutter, other atrial arrythmias) WPs, recert if?

A-fib: WP 1 month (unique) anticoagulated -A-Flutter: 1 mos post isthmus ablation -Other atrial arrythmias (eg. WPW): Asx for 1 mos and annual f/u Annual recert IF -Rate controlled -Treatment for prevention of emboli -No underlying DQ disease -Clearance from cardiovascular specialist

DQ drugs:

AMphetamines Nacrs Any habit forming med Methadone! MJ

If you hear a murmur during your exam...

Additional evaluation is recommended when murmurs are: •Systolic, grade I or II, and the driver has signs or symptoms of heart disease. •Systolic and grade III or higher. •Holosystolic or late systolic. •Diastolic or continuous. When in doubt about the severity of a heart murmur, you should obtain additional evaluation.

Stage 2 HTN f/u:

Advise driver that follow-up qualification requires BP < 140/90 at which time a 1-yr cert may be issued frmo date of ORIGINAL exam, and failure to lower BP < 140/90 = DQ

Cardiomyopathy cert and required tests?

Annual cert Annual cardiology eval, ECHO, Holter

Meds commonly used for vertigo:

Antihistamines (sedative - wait 12 hours to drive) Benzodiazepines Phenothiazines

Interstate commerce definition?

Any material transported from 1 state to another state, even if the individual driver never leaves 1 state, that: a) >26,001 lbs b) 9-15 passengers for compensation c) 16+ passengers regardless of compensation d) that requires placarding for hazardous materials

What does 4 things can "severe hypoglycemic episode" include?

Any of the following: 1) Seizure 2) LOC 3) Needs assistance from another person 4) Period of impaired cognitive function that occurred without warning

Most likely cause of sudden driver incapacitation?

Arrythmia

Aneurysms in other vessels?

Assess risk of rupture

CHF certify if?

Asx No ventricular arrythmias LVEF>40 Under care of cardiologist

Expiration date of card, when does it officially expire?

At midnight on the day specified. No grace period.

Audiometry standards:

Audiometry: Better than 40 DB at 500/1000/2000 Hz add together and divide by 3 to get the average.

Neuromuscular Disorders:

Autonomic Neuropathy: 2 year max Disorders of muscle activity: 2 year max NO cert: myotonia, Isaac's synd, Stiff-man syndrome Motor neuron Dx: EX- herediaty spinal muscular atrophy and ALS = NO cert. (Can appeal)

EVAR WP and f/u?

Base it on the follow up protocol of the treating provider. If every 3 month follow up than every 3 month cert.