Medical_Examiner_DetailedContentOutline.pdf

Effective: May 2007 Revised: October 2013

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National Registry of Certified Medical Examiners (NRCME) FMCSA Medical Examiner Detailed Content Outline*

Open cells show an examination could include items from indicated cognitive levels.

Shaded cells prevent appearance of items on examinations.

Items

Cognitive Level

R e c a ll

A p p lic a tio n

A a ly s is

T o ta ls

I. DRIVER’S MEDICAL INFORMATION 23 33 14 70

A. Identification and History 4 6 10 20

1. Verify the identity of the driver

2. Ensure the driver signs the driver’s statement about health history

3. Identify, query, and note issues in a driver’s medical record and / or health history as available, which may include

a. specifics regarding any affirmative responses in the history

b. any illness, surgery, or injury in the last five years

c. any other hospitalizations or surgeries

d. any recent changes in health status

e. whether he / she has any medical conditions or current complaints

f. any incidents of disability / physical limitations

g. limitations placed during prior FMCSA exams

h. current OTC and prescription medications and supplements, and potential side effects, which may be potentially disqualifying

i. his or her use of recreational / addictive substances e.g., nicotine alcohol inhalants

j. weight disorders e.g., unexplained loss unexplained gain obesity

k. disorders of the eyes e.g., retinopathy cataracts aphakia glaucoma macular degeneration monocular vision

l. disorders of the ears e.g., hearing loss hearing aids vertigo

Meniere’s Tinnitus implants

m. cardiac symptoms e.g., syncope dyspnea chest pain palpitations

n. cardiovascular diseases e.g., hypertension congestive heart failure myocardial infarction coronary insufficiency thrombosis

o. hematologic disorders e.g., bleeding disorders anemia cancer organ transplant history

p. pulmonary symptoms e.g., dyspnea orthopnea chronic cough

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Items

Cognitive Level

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q. pulmonary diseases e.g., asthma chronic lung disorders tuberculosis previous pulmonary embolus pneumothorax

r. sleep disorders e.g., sleep apnea narcolepsy insomnia daytime sleepiness loud snoring testing and / or treatments

s. gastrointestinal disorders e.g., pancreatitis ulcers ulcerative colitis cirrhosis hepatitis irritable bowel syndrome hernias

t. genitourinary disorders e.g., polycystic nephrotic syndrome kidney stones renal failure hernias

u. diabetes mellitus weight loss duration on current medications medication side effects complications from diabetes availability of emergency glucose supply presence and frequency of hypoglycemic / hyperglycemic episodes / reactions

v. other endocrine disorders (e.g., thyroid disorders, interventions / treatment)

w. musculoskeletal disorders e.g., amputations arthritis spinal surgery

x. neoplastic disorders e.g., leukemia brain cancer bone cancer breast cancer lung cancer

y. substance use and abuse e.g., alcohol narcotics illicit or legal drugs

z. neurologic disorders e.g., loss of consciousness seizures stroke / TIA headaches / migraines numbness / weakness

aa. psychiatric disorders e.g., schizophrenia depression anxiety bipolar

ADHD

interventions / treatment

bb. other conditions that could impair a driver’s ability to safely function

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Items

Cognitive Level

R e c a ll

A p p lic a a ly

B. Physical Examination and Evaluation 8 15 2 25

1. Ensure the driver is properly clothed for the physical examination

2. Record height and weight, and note whether a driver is overweight or underweight

3. Examine the driver’s eyes and note

a. distant acuity in each and both eyes (Snellen comparable values)

b. whether corrective lenses are required to meet the standard

c. horizontal field of vision in each eye

d. color recognition

e. presence or absence of monocular vision

f. reactivity to light and pupillary equality

g. evidence of nystagmus and exophthalmos

h. evaluation of extraocular movements

i. fundoscopic examination results

4. Examine the driver’s ears and note

a. abnormalities of the ear canal and tympanic membrane

b. whisper test and / or audiometric results (in ANSI standard units) as indicated

c. presence or absence of a hearing aid and whether required to meet the standard

5. Examine the driver’s mouth and throat, and note conditions that may interfere with breathing, speaking, or swallowing

6. Examine the driver’s neck and note

a. range of motion

b. soft tissue palpation / examination (e.g., lymph nodes, thyroid gland)

7. Examine the driver’s heart

a. chest inspection (e.g., surgical scars, pacemaker / IAD)

b. thrills, murmurs, extra sounds, and enlargement

c. blood pressure and pulse (rate and rhythm)

d. additional signs of disease e.g., edema bruits diaphoresis distended neck veins

8. Examine the driver’s lungs, chest, and thorax, excluding breasts, and note

a. respiratory rate and pattern

b. abnormal breath sounds

c. abnormal chest wall configuration / palpation

d. scars

9. Examine the driver’s abdomen and note

a. surgical scars

b. an enlarged liver or spleen

c. abnormal masses or bruits / pulsation

d. abdominal tenderness

e. hernias e.g., inguinal umbilical ventral femoral

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Items

Cognitive Level

R e c a ll

A p p lic a a ly

10. Examine the driver’s spine and note

a. surgical scars and deformities

b. tenderness and muscle spasm

c. loss in range of motion and painful motion

d. kyphosis, scoliosis, or other spinal deformities

11. Examine the driver’s extremities and note

a. gait, mobility, and posture while bearing his or her weight; limping or signs of pain

b. loss, impairment, or use of orthosis

c. deformities, atrophy, weakness, paralysis, surgical scars

d. elbow and shoulder strength, function, and mobility

e. handgrip and prehension relative to requirements for controlling a steering wheel and gear shift

f. varicosities, skin abnormalities, and cyanosis, clubbing, or edema

g. leg length discrepancy; lower extremity strength, motion, and function

12. Examine the driver’s neurologic status and note

a. impaired equilibrium, coordination or speech pattern (e.g., Romberg, finger to nose test)

b. gait disorders

c. sensory or positional abnormalities

d. tremor

e. radicular signs

f. reflexes e.g., asymmetric deep-tendon normal / abnormal patellar

Babinski

13. Test the driver’s urine and note specific gravity, protein, blood, and glucose

14. Examine the driver’s mental status and note

a. comprehension and interaction

b. cognitive impairment e.g., orientation intellect memory obsessions circumstantial / tangential speech

c. signs of depression, paranoia, antagonism, or aggressiveness that may require follow-up with a mental health professional

C. Diagnostic Tests and / or Referrals 6 10 2 18

1. Obtain additional information when indicated by

a. audiometrics

b. cardiovascular studies e.g., electrocardiogram stress test ejection fraction vascular studies

c. blood analyses e.g., creatinine electrolytes toxicology lipids blood chemistries

d. chest radiograph

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Items

Cognitive Level

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e. respiratory tests e.g., spirometry diffusion lung volumes oximetry or arterial blood gas analysis with or without exercise

f. sleep studies

g. drug level monitoring

h. other tests

2. Refer a driver who exhibits evidence of any of the following disorders for follow-up care and evaluation by an appropriate specialist or primary care provider vision (e.g., retinopathy, macular degeneration) cardiac (e.g., myocardial infarction, coronary insufficiency, blood pressure control) pulmonary (e.g., emphysema, fibrosis) endocrine (e.g., diabetes) musculoskeletal (e.g., arthritis, neuromuscular disease) neurologic (e.g., seizures) sleep (e.g., obstructive sleep apnea) mental / emotional health (e.g., depression, schizophrenia)

3. Refer a driver

a. with limitations in extremity movement for an on-road performance evaluation and / or skill performance evaluation

b. for conditions not directly related to certification, but detected during the examination

D. Documentation of Ancillary Information 5 2 0 7

1. Record / include results as available with other information about the driver, which may include

a. audiometrics

b. cardiovascular studies e.g., electrocardiogram stress test ejection fraction vascular studies

c. blood analyses e.g., creatinine electrolytes toxicology lipids blood chemistries

d. chest radiograph

e. respiratory tests e.g., spirometry diffusion lung volumes oximetry or arterial blood gas analysis with or without exercise

f. sleep studies

g. drug level monitoring

h. other tests

i. treating physician’s work release

2. Integrate a specialist’s evaluation with other information about the driver

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Items

Cognitive Level

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3. Include an annual ophthalmologist’s or optometrist’s report for a driver who was qualified under a vision exemption

4. Include information for a driver who is qualified under a diabetes exemption, which includes an endocrinologist’s and ophthalmologist’s / optometrist’s report as required

5. Include if available

a. a current skill performance evaluation certificate

b. documentation of intracity zone exemption

6. Review results of SAP evaluations for alcohol and drug use and / or abuse for a driver with

a. alcoholism who completed counseling and treatment to the point of full recovery

b. prohibited drug use who shows evidence he or she is now free from such use

II. DETERMINATION OF DRIVER’S QUALIFICATIONS AND DISPOSITION 7 12 11 30

A. Health Education Counseling 2 1 1 4

1. Explain to a driver consequences of non-compliance with a care plan for conditions that have been advised for periodic monitoring with primary healthcare provider

2. Advise a driver

a. regarding side effects and interactions of medications and supplements (e.g., narcotics, anticoagulants, psychotropics) including those acquired over the counter (e.g., antihistamines, cold and cough medications) that could negatively affect his or her driving

b. that fatigue, lack of sleep, undesirable diet, emotional conditions, stress, and other illnesses can affect safe driving

c. with contact lenses he or she should carry a pair of glasses while driving

d. with a hearing aid he / she should possess a spare power source for the device while driving

e. who has had a deep vein thrombosis event of risks associated with inactivity while driving and interventions that could prevent another thrombotic event

f. who has diabetes about glucose monitoring frequencies and the minimum threshold while driving

g. with a diabetes exemption, he / she should

1) possess a rapidly absorbable form of glucose while driving

2) self-monitor blood glucose one hour before driving and at least once every four hours while driving

3) comply with each condition of his / her exemption

4) plan to submit glucose monitoring logs for each annual recertification

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Items

Cognitive Level

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3. Inform the driver of the rationale for delaying or potentially disqualifying certification, which may include the immediate post-operative period a vision disability (e.g., retinopathy, macular degeneration) a cardiac event (e.g., myocardial infarction, coronary insufficiency) a chronic pulmonary exacerbation (e.g., emphysema, fibrosis) uncontrolled hypertension endocrine dysfunctions (e.g., diabetes) musculoskeletal challenges (e.g., arthritis, neuromuscular disease) a neurologic event (e.g., seizures, stroke, TIA) a sleep disorder (e.g., obstructive sleep apnea) mental health dysfunctions (e.g., depression, bipolar)

B. Risk Assessment 2 4 8 14

1. Consider a driver’s ability to couple and uncouple trailers from a tractor load or unload several thousand pounds of freight install and remove tire chains manipulate and secure tarpaulins that cover open trailer move one’s own body through space while climbing ladders; bending, stooping, and crouching; entering and exiting the cab manipulate an oversized steering wheel shift through several gears using a manual transmission perform precision prehension and power grasping use arms, feet, and legs during CMV operation

2. Review Skill Performance Evaluation (SPE) cases

a. identify terms, conditions, and limitations set forth in a driver’s SPE Certificate

b. ensure an appropriate SPE Certificate from the FMCSA Division Administrator has been granted to a driver who lost a foot, leg, hand, or arm

3. Consider a driver’s cognitive ability to plan a travel route inspect the operating condition of a tractor and / or trailer monitor and adjust to a complex driving situation maneuver through crowded areas quickly alter the course of vehicle to avoid trouble

4. Consider general health and wellness factors such as

a. adverse health effects associated with rotating work schedules and irregular sleep patterns

b. long-term effects of fatigue associated with extended work hours without breaks

c. risk factors associated with common dietary choices available to drivers

d. stressors likely associated with extended time away from a driver’s social support system

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Items

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e. short- and long-term health effects of stress from tight pickup and delivery schedules irregular work, rest, and eating patterns / dietary choices adverse road, weather, and traffic conditions exposure to temperature extremes, vibration, and noise transporting passengers or hazardous products

5. Integrate FMCSA medical advisory criteria and guidelines regarding a driver’s condition into the risk assessment

6. Consider for documented conditions the rate of progression, degree of control, and likelihood of sudden incapacitation e.g., cardiovascular neurologic respiratory musculoskeletal

7. Support the rationale for using FMCSA guidelines that have not been published in regulations yet

C. Certification Outcomes and Intervals 3 7 2 12

1. Apply nondiscretionary certification standards to disqualify a driver

a. with a history of epilepsy

b. with diabetes requiring insulin control (unless accompanied by an exemption)

c. when vision parameters (e.g., acuity, horizontal field of vision, color) fall below minimum standards unless accompanied by an exemption

d. when hearing measurements with or without a hearing aid fall below minimum standards

2. Disqualify a driver who

a. is currently taking methadone

b. has a current clinical diagnosis of alcoholism

c. uses a controlled substance including a narcotic, an amphetamine, or another habit-forming drug without a prescription from the treating physician

3. Disqualify a driver when evidence shows a condition exists that will likely interfere with the safe operation of a CMV, which may include sufficient supporting opinions and information from specialists

4. Document the reason(s) for the disqualification and / or referral

5. Advise a driver of the reasons for a disqualification decision and what a driver could do to become qualified

6. Certify a driver for an appropriate interval

7. Indicate certification status, which may require waiver / exemption, which the medical examiner identifies wearing corrective lenses wearing a hearing aid a Skill Performance Evaluation Certificate

8. Advise a driver certified with a limited interval to return for recertification with the appropriate documentation for his or her condition

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Items

Cognitive Level

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9. Complete a medical examination report and medical certificate / card ensure use of currently required examination form ensure the form includes the examiner’s name, examination date, office address, and telephone number ensure the driver signs the medical certificate / card

Totals 30 45 25 100

* Each new test form will include one 20-item pretest (e.g., 1A, 2A).