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Certified Medical Examiner - FMCSA > CME Content > Flashcards

CME Content Flashcards

1
Q

Glucose - sugar in the blood

A

Normal: 70-99 mg/dL

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2
Q

Sodium (Na) - electrolyte

A

Normal: 135-145 mEq/L

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3
Q

Chloride (Cl) electrolyte

A

Normal: 96-106 mmol/L

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4
Q

Potassium (K) - electrolyte

A

Normal: 3.5-5.5 mEq/L

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5
Q

Carbon Dioxide (CO2) - gaseous waste product

A

Normal: 20-29 mmol/L

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6
Q

Blood Urea Nitrogen (BUN) - waste product of the liver carried to the liver and excreted through urine

A

Normal: 7-20 mg/dL

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7
Q

Creatinine - chemical waste product of muscle metabolism

A

Normal: 0.8-1.4 mg/dL

can be tested in blood or urine

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8
Q

Calcium (Ca) - mineral stored in the bones

A

Normal: 8.5-10.9 mg/dL

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9
Q

Magnesium (Mg) - electrolyte

A

Normal: 1.8-2.6 mEq/L

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10
Q

Protein (Total) - chains of amino acids essential for growth and repair of cells

A

Normal: 6.3-7.9 g/dL

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11
Q

Albumin - protein that keeps fluid from leaking out of blood vessels and that nourishes tissues

A

Normal: 3.9-5.0 g/dL

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12
Q

Globulin - alpha, beta, and gamma proteins

A

Normal: 2.0-3.5 g/dL

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13
Q

Bilirubin - pigment in bile, a digestive fluid produced b the liver

A

Normal: 0-0.3 mg/dL

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14
Q

Alkaline Phosphatase (ALP) - enzyme found in liver and bones

A

Normal: 50-160 IU/L

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15
Q

Alanine Amino-transferase (ALT) - enzyme found mostly in the liver

A

Normal: 8-37 IU/L

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16
Q

Aspartate Amino-transferase (AST) - enzyme found in the liver, muscles, and other tissues

A

Normal: 10-34 IU/L

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17
Q

Glomerular Filtration Rate (GFR) - checks how well the kidneys are working by estimating how much blood passes through the glomeruli each minute

A

Normal: 90-120 mL/min/1.73 m2

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18
Q

Body System 1

A

General

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19
Q

Body System 2

A

Skin

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20
Q

Body System 3

A

Eyes

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21
Q

Body System 4

A

Ears

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22
Q

Body System 5

A

Mouth/throat

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23
Q

Body System 6

A

Cardiovascular

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24
Q

Body System 7

A

Lungs/chest

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25
Q

Body System 8

A

Abdomen

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26
Q

Body System 9

A

GU (including hernias)

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27
Q

Body System 10

A

Back/spine

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28
Q

Body System 11

A

Extremities/joints

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29
Q

Body System 12

A

Neurological (including reflexes)

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30
Q

Body System 13

A

Gait

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31
Q

Body System 14

A

Vascular

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32
Q

DUI - alcohol (as prescribed under State law)

A 
1st offense = 1 year
1st offense (hazardous materials) = 3 years
2nd offense = life
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33
Q

DUI - alcohol (blood concentration >= 0.04)

A 
1st offense = 1 year
1st offense (hazardous materials) = 3 years
2nd offense = life (possible reinstatement after 10 years after completion of state-approved rehab program)
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34
Q

DUI - controlled substance

A 
1st offense = 1 year
1st offense (hazardous materials) = 3 years
2nd offense = life (possible reinstatement after 10 years after completion of state-approved rehab program)
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35
Q

Refusing to take an alcohol test

A 
1st offense = 1 year
1st offense (hazardous materials) = 3 years
2nd offense = life
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36
Q

Leaving the scene of an accident

A 
1st offense = 1 year
1st offense (hazardous materials) = 3 years
2nd offense = life
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37
Q

Using CMV to commit a (non-drug-related) felony

A 
1st offense = 1 year
1st offense (hazardous materials) = 3 years
2nd offense = life
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38
Q

Driving with a revoked, suspended, or disqualified license

A 
1st offense = 1 year
1st offense (hazardous materials) = 3 years
2nd offense = life
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39
Q

Causing a fatality through negligent operation of a CMV

A 
1st offense = 1 year
1st offense (hazardous materials) = 3 years
2nd offense = life
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40
Q

Using CMV in the commission of a felony involving the manufacture, distribution, or dispensing of a controlled substance (whether hauling hazardous material or not)

A

1st offense = life (permanent)

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41
Q

Moving violations (speeding in excess of 15 mph over the limit, reckless driving, improper lane changes, tailgating, driving without CDL in possession, driving without proper class of CDL, texting while driving)

A

2nd offense = 60 day suspension

3 or higher offense = 120 day suspension

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42
Q

Stage 1 HTN (140-159/90-99)

A

Certify: 1 year
Recertify: 1 year if BP < 140/90 or 3 months if not

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43
Q

Stage 2 HTN (160-179/100-109)

A

Certify: 3 months (refer to specialist)
Recertify: 1 year if BP < 140/90

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44
Q

Stage 3 HTN (>=180/110)

A

Disqualify

Recertification: never more than 6 months and only if BP < 140/90

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45
Q

Monocular vision

A

Disqualify

Certify 1 year with exemption (renew exemption q 2 years)

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46
Q

Meniere’s disease

A

Disqualify

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47
Q

Uncontrolled vertigo

A

Disqualify

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48
Q

Labyrinthine fistula

A

Disqualify

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49
Q

Nonfunctioning labyrinth

A

Disqualify

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50
Q

Secondary HTN

A

if not treated through surgery - use guidelines for essential HTN
Waiting period: 3 months after surgical correction of underlying disorder
Certify: 1 year
Recertification: annual

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51
Q

Anticoagulant therapy

A

Waiting period: >= 1 month stabilized on Tx
Certify: 1 year (must provide documentation of INR results at exam with at least monthly INR testing)
Recertification: annual

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52
Q

Abdominal aortic aneurysm (< 4 cm 4-5 cm with clearance, or any size but repaired)

A

Waiting period: 3 months post-surgical repair
Certify: 1 year
Recertification: annual

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53
Q

Abdominal aortic aneurysm (symptomatic, recommended for repair, increased > 5 cm in size in 6 months, or > 5 cm)

A

Disqualify

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54
Q

Acute DVT

A

Waiting period: until etiology has been confirmed and Tx initiated
Certify: 1 year (if well managed, under supervision, and on prescription medications)
Recertification: annual

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55
Q

Chronic thrombotic venous disease

A

Certify: 2 years (if stable and asymptomatic)
Recertification: biannual

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56
Q

Intermittent claudication

A

Waiting period: do not certify if pain at rest
Certify: 1 year
Recertification: annual

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57
Q

Pulmonary emboli

A

S/S: sharp pain with cough
Waiting period: 3 months post-surgical repair OR without PE (do not certify if symptomatic - dyspnea, chest pain, SOB)
Certify: 1 year
Recertification: annual

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58
Q

Thoracic aneurysm (< 3.5 cm)

A

weakened and bulging area in upper part of aorta
Waiting period: 3 months post-surgical repair
Certify: 1 year
Recertification: annual

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59
Q

Varicose veins

A

Waiting period: do not certify until etiology confirmed and Tx effective - can be harmless but painful or sign of pulmonary/vascular disorder => refer to specialist
Certify: 2 years
Recertification: biannual

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60
Q

Implantable cardioverter-defibrillators (ICD)

A

Disqualify (do not certify driver with pacemaker/ICD, even if ICD not activated) - treat cardiac arrest, ventricular tachycardia, and ventricular fibrillation through delivery of rapid electrical shocks (treat, but do not prevent arrhythmias)

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61
Q

Pacemaker (sinus node dysfunction/AV block)

A

Waiting period: 1 month post-implantation
Certify: 1 year (documentation of regular checks)
Recertification: annual

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62
Q

Pacemaker (neurocardiogenic syncope/hypersensitive carotid sinus w/syncope)

A

Waiting period: 3 months post-implantation
Certify: 1 year (documentation of regular checks)
Recertification: annual

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63
Q

Atrial fibrillation

A

Waiting period: 1 month with adequate anticoagulation or ablation
Certify: 1 year (do not certify if symptomatic)
Recertification: annual

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64
Q

Ventricular arrhythmia

A

Waiting period: 1 month after Tx
Certify: 1 year (do not certify if driver has LVEF < 40%, hypertrophic cardiomyopathy, long QT interval, Brugada syndrome)
Recertification: annual

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65
Q

Acute MI

A

Waiting period: 2 months (LVEF >= 40%)
Certify: 1 year (do not certify if resting angina, ETT < 6 METs, ischemic change on rest ECG, intolerance to therapy)
Recertification: annual (with biennial ETT)

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66
Q

Angina pectoris

A

Waiting period: 3 months with no resting angina or change in pattern (satisfactory ETT with cardiovascular evaluation q 2 years)
Certify: 1 year (do not certify if driver has unstable angina within 3 months of exam)
Recertification: annual

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67
Q

Coronary Heart Disease (CHD) risk-equivalent (DM, PVD, Framingham risk 20% CHD in next 10 years, over age 45 with multiple risk factors for CHD)

A

Certify: 1 year
Recertification: annual

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68
Q

Coronary artery bypass grafting (CABG) surgery

A

Waiting period: 3 months post-surgery (or until sternum has healed)
Certify: 1 year (only if LVEF >= 40% - do not certify if driver is symptomatic, has LVEF < 40%, not cleared by cardiologist, unhealed sternum)
Recertification: Annual (annual ETT 5 yrs. Post-CABG)

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69
Q

Percutaneous coronary intervention (PCI)- angioplasty

A

Waiting period: 1 week
Certify: Initial certification = 6 months (driver should bring results of ETT 3-6 months post intervention) then 1 year
Recertification: annual (if ETT normal)

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70
Q

Ebstein anomaly

A

congenital downward displacement of the tricuspid valve
Certify: 1 year
Recertification: annual

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71
Q

Heart transplantation

A

Waiting period: 1 year
Certify: 6 months (evaluation should be done by cardiologist)
Recertification: 6 months

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72
Q

Hypertrophic cardiomyopathy

A

Disqualify - left ventricle or septum between ventricles enlarges (heart cannot relax properly between beats and fills with less blood = insufficient blood flow to body)

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73
Q

Restrictive cardiomyopathy

A

Disqualify

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74
Q

Syncope

A

loss of consciousness
Waiting period: identify and treat underlying disorder
Certify: 1 year
Recertification: annual

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75
Q

Heart murmurs

A

Waiting period: 3 months after valve repair
Certify: 6 mos. w/o valve repair and 1 yr. w/valve repair (ECG every 2-3 years)
Recertification: annual

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76
Q

Mitral Stenosis

A

Mild: mitral valve area (MVA) >= 1.6 cm (certify)
Moderate: MVA 1.0-1.6 cm
Severe: MVA < 1.0 (disqualify)

Waiting period: 4 wks. (post-percutaneous balloon valvotomy)/3 mos. (Post-surgery)
Certify: 1 year (annual CXR, ECG, 2D echocardiography with Doppler)
Recertification: annual

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77
Q

Mitral Valve Prolapse

A

Certify: 1 year
Recertification: annual (with Echo if mitral regurgitation)

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78
Q

Prosthetic valves

A

Waiting period: 3 months post-surgery
Certify: 1 year
Recertification: annual

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79
Q

Pulmonary valve stenosis

A

Waiting period: 1 mo. (post-balloon valvuloplasty)/3 mos (post-surgical valvotomy)
Certify: 1 year
Recertification: annual
do not certify: symptomatic, pulmonary valve peak gradient > 50 mm Hg, right ventricular pressure > 50%, > mild RV hypertrophy/dysfunction, > moderate pulmonary valve regurgitation, main pulmonary artery diameter > 5 cm

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80
Q

Antihistamine therapy use

A

Certify: 2 years (must wait 12 hours before operating vehicle)
Recertification: biennial

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81
Q

Asthma

A

Certify: 2 years (do not certify if asthma is poorly controlled)
Recertification: biennial

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82
Q

Hypersensitivity pneumonitis (immune-mediated granulomatous interstitial pneumonitis)

A

Certify: 2 years (CXR can reveal extent of interstitial disease)
Recertification: biennial

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83
Q

Chronic obstructive pulmonary disease (COPD)

A

Certify: 2 years (do not certify w/hypoxemia at rest, chronic respiratory failure, Hx of cough with syncope)
Recertification: biennial

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84
Q

Acute respiratory disease

A

Certify: 2 years (wait 12 hours after taking sedatives)
Recertification: biennial

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85
Q

Atypical TB

A

Certify: 2 years
Recertification: biennial

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86
Q

Pulmonary TB

A

Certify: 2 years (do not certify with chronic TB, noncompliance with therapy, incomplete streptomycin therapy)
Recertification: biennial

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87
Q

Chest wall deformity

A

Certify: 2 years (do not certify if hypoxemia at rest, chronic respiratory failure, Hx of cough with syncope, < spirometry, unstable)
Recertification: biennial

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88
Q

Interstitial lung diseases (ILDs)

A

Certify: 2 years (do not certify if hypoxemia at rest, chronic respiratory failure, Hx of cough with syncope)
Recertification: biennial

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89
Q

Traumatic or Spontaneous Pneumothorax

A

Certify: 2 years (confirm recovery with CXR)

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90
Q

Cor pulmonale (enlargement of the right ventricle secondary to lung disease)

A

Certify: 2 years (do not certify if dyspnea at rest, dizziness, hypotension, PaO2 < 65 mm Hg)
Recertification: biennial

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91
Q

Pulmonary hypertension (pulmonary artery pressure greater than 50% systemic systolic blood pressure)

A

S/S: chest pain, swollen ankles, SOB
Certify: 1 year (do not certify if dyspnea at rest, dizziness, hypotension, PaO2 < 65 mm Hg)
Recertification: annual

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92
Q

Anticonvulsant therapyfor pain

A

Certify: 2 years (do not certify if Tx used to prevent seizures)
Recertification: annual

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93
Q

Provoked (1 time seizure)/childhood febrile seizures

A

Certify: 2 years
Recertification: biennial

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94
Q

Unprovoked Seizure (mild without early seizure)

A

Waiting period: 1 year seizure free and off anticonvulsant medications
Certify: 1 year
Recertification: annual

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95
Q

Unprovoked Seizure (moderate without early seizure)

A

Waiting period: 2 years seizure free and off anticonvulsant medications
Certify: 1 year
Recertification: annual

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96
Q

Unprovoked Seizure (moderate with early seizure) or single unprovoked seizure

A

Waiting period: 5 years seizure free and off anticonvulsant medications
Certify: 1 year
Recertification: annual

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97
Q

Unprovoked Seizure/Hx of Epilepsy (2 or more unprovoked seizures)

A

Waiting period: 10 years seizure free and off anticonvulsant medications
Certify: 1 year
Recertification: annual

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98
Q

Headaches

A

Certify: 2 years
Recertification: biennial

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99
Q

Benign positional vertigo/Acute and chronic peripheral vestibulopathy

A

Waiting period: 2 months asymptomatic
Certify: 2 years
Recertification: biennial
do not certify: use of benzodiazepines/phenothiazines for treatment

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100
Q

Aseptic meningitis

A

Certify: 2 years
Recertification: biennial

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101
Q

Bacterial meningitis or Viral encephalitis without early seizures

A

Waiting period: 1 year seizure free and off anticonvulsant medications
Certify: 2 years
Recertification: annual

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102
Q

Bacterial meningitis with early seizures

A

Waiting period: 5 years seizure free and off anticonvulsant medications
Certify: 2 years
Recertification: annual

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103
Q

Viral encephalitis with early seizures

A

Waiting period: 10 years seizure free and off anticonvulsant medications
Certify: 2 years
Recertification: annual

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104
Q

Autonomic neuropathy (affects the nerves that regulate vital functions)

A

Certify: 2 years (do not certify with resting tachycardia or orthostatic BP)
Recertification: biennial

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105
Q

Myotonia

A

Disqualify

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106
Q

Isaac’s syndrome (rare neuromuscular disorder that is characterized by progressive muscle stiffness; continuously contracting or twitching muscles [myokymia]; and diminished reflexes)

A

Disqualify

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107
Q

Stiff-man syndrome

A

Disqualify

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108
Q

Congenital myopathies

A

Disqualify

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109
Q

Metabolic muscle diseases(conditions affecting the energy metabolism of muscle)

A

Disqualify

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110
Q

Motor neuron disease(spinal muscular atrophy, amyotrophic lateral sclerosis)

A

Disqualify

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111
Q

Muscular dystrophy

A

Disqualify

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112
Q

Neuromuscular junction disorders (myasthenia gravis, myastenic syndrome)

A

Disqualify (easy fatigability)

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113
Q

Peripheral neuropathy

A

Disqualify (interferes with sensation) - protein in the urine is often the first sign

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114
Q

Brain tumors (infratentorial meningiomas, acoustic neuromas, pituitary adenomas, spinal benign tumors)

A

Waiting period: 1 year post-surgical removal
Certify: 1 year (with no evidence of new tumors)
Recertification: annual

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115
Q

CNS tumors (benign supratentorial tumors, spinal tumors)

A

Waiting period: 2-4 years post-surgical removal
Certify: 1 year (with no evidence of new tumors)
Recertification: annual

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116
Q

Dementia (Alzheimer’s/Pick’s disease)

A

Disqualify

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117
Q

Stroke/intracerebral and subarachnoid hemorrhage/TIA

A

Waiting period: 1 yr. (no risk for seizure)/5 yrs. (risk for seizure)
Certify: 1 year (no risk for seizure - cerebellum or brainstem vascular lesions/risk for seizure - cortical or subcortical deficits)
Recertification: annual

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118
Q

Mild TBI without early seizures

A

Certify: 2 years
Recertification: biennial

119
Q

Mild TBI w/early seizure or Moderate TBI w/out early seizures

A

Waiting period: 4 years seizure free and off anticonvulsant medications
Certify: 1 year
Recertification: annual

120
Q

Moderate TBI w/early seizures

A

Waiting period: 5 years seizure free and off anticonvulsant medications
Certify: 1 year
Recertification: annual

121
Q

Severe TBI (penetrates dura - with or without early seizures)

A

Disqualify

122
Q

Fixed deficit on extremity and SPE issued

A

Waiting period: driver otherwise qualified to drive; SPE renewed every 2 years (do not certify if impairment affects torso)
Certify: 2 years
Recertification: biennial

123
Q

Diabetes Mellitus (without insulin use)

A

Certify: 2 years (assess with urinalysis and A1c - greater than 10% = poor glucose control)
Recertification: biennial

124
Q

Insulin-dependent diabetes

A

Waiting period: 1 mo. (previous Dx and not on insulin), 2 mos. (newly diagnosed)
Certify: 1 year (driver should present with MCSA-5870 form and should carry 20 g glucose tablets)
Recertification: annual (by endocrinologist)

Drivers certified in Canada or Mexico cannot be certified in the USA

125
Q

Incretin mimetic (exenatide/Byetta - reduces fasting and postprandial glucose concentrations)use

A

Certify: 1 year (Incretin mimetics are not insulin and can be used without an exemption)
Recertification: annual

126
Q

Hernia

A

can affect driver’s ability to load, unload, couple, and uncouple vehicle
Certify: 2 years
Recertification: biennial

127
Q

Nephropathy (diabetic-related)

A

Certify: 2 years (check for proteinuria with urinalysis)
Recertification: biennial

128
Q

ESRD (on hemodialysis)

A

Disqualify

129
Q

Antidepressant use

A

Waiting period: as necessary until medication use is adequate and stable
Certify: 1 year (do not certify if driver using 1st general antidepressant - amitriptyline/Elavil or imipramine/Tofranil)
Recertification: annual

130
Q

Hypnotic medications

A

Certify: 2 years (only if short acting - 1/2 life < 5 hrs., lowest effective dose, and used < 2 weeks)
Recertification: annual

Example: Ambien lowest dosage is 5 mg

131
Q

Non-sedating anxiolytic

A

Certify: 2 years
Recertification: annual

132
Q

Sedating anxiolytics (Benzodiazepines: Ativan, Halcion, Librium, Valium, Xanax, Rohypnol)

A

Disqualify

133
Q

Central nervous system (CNS) stimulants (e.g., dextroamphetamine, methylphenidate,pemoline)

A

Certify: 1 year (only if used to treat ADHD - disqualify if used to treat narcolepsy)
Recertification: annual

134
Q

Narcolepsy

A

Disqualify

135
Q

Electroconvulsive therapy (ECT)

A

Waiting period: 6 months symptom free following last course of ECT
Certify: 1 year (do not certify if driver receiving maintenance ECT)
Recertification: annual

136
Q

Lithium (Eskalith)

A

Certify: 1 year (do not certify if driver is symptomatic or lithium is not in therapeutic range)

137
Q

ADHD

A

Waiting period: as necessary until cause is confirmed and treatment deemed adequate
Certify: 1 year - do not certify if active psychosis, prominent negative symptoms, or side effects of medications interfere with driving
Recertification: annual

138
Q

Nonpsychotic major depression unaccompanied bysuicidal behavior

A

Waiting period: 6 months
Certify: 1 year
Recertification: annual

139
Q

Severe depressive episode/suicide attempt/manicepisode

A

Waiting period: 1 year
Certify: 1 year (evaluation every 2 years by mental health professional)
Recertification: annual

140
Q

Personality disorder

A

Certify: 1 year
Recertification: annual

141
Q

Schizophrenia

A

Waiting period: 6 mos. (brief reactive psychosis or schizophreniform disorder); 1 yr. (any other psychotic disorder)
Certify: 1 year
Recertification: annual

142
Q

Alcohol use

A

Certify: 2 years (If SAP finds that driver does not have alcoholism; attendance at 12 step groups is not disqualifying)
Recertification: annual

143
Q

Alcoholism

A

Disqualify (can be reinstated following completion of SAP) - S/S: hand shaking, memory loss, anxiety, insomnia, mood swings, smell of alcohol

144
Q

History of drug abuse

A

Certify: 2 years (SAP must provide clearance; free of active use)
Recertification: biennial

145
Q

Schedule I drug use /amphetamines/narcotics/methadone/marijuana

A

Disqualify (methadone/marijuana - even if State allows legal use or use is prescribe by medical profession)

146
Q

Seizure Exemption - Hx of Epilepsy

A

Seizure-free for 8 years, on or off medication (if on medications, 8 years since the date the medication was discontinued)
If taking anti-seizure medications - plan for medication should be stable for 2 years (no changes in medication, dosage, or frequency)
Certify: 1 year
Recertification: annual

147
Q

Seizure Exemption - Single unprovoked seizure (no known trigger for the seizure)

A

Seizure-free for 4 years, on or off medication
If taking anti-seizure medications - plan for medication should be stable for 2 years (no changes in medication, dosage, or frequency)
Certify: 2 years
Recertification: annual

148
Q

Seizure Exemption - Single provoked seizure (known trigger for the seizure)

A

Low risk for recurrence (cleared by neurologist)
Moderate to high risk factors for recurrence should be seizure-free for 8 years, on or off medication
Certify: 1 year
Recertification: annual

149
Q

Acute seizure with acute structural CNS insult (stable)

A

Waiting period: 4 years
Certify: 1 year
Recertification: annual

150
Q

Topics for Driver Education

A

Medication side effects, Rx warning labels, seeking care for conditions that do not affect driving safety

151
Q

CDL Classes

A

A - any combination of vehicles with gross weight >= 26,001
B - single vehicle >= 26,001 or any vehicle towing another vehicle weighing up to 10,000 pounds
C - doesn’t meet A or B and transports >= 16 passengers (including the driver) or hazardous materials

152
Q

FMCSA requirements for CDL

A

(1) no use of Schedule I drugs
(2) visual acuity >= 20/40 in each eye, >= 20/40 distant visual acuity, field of vision >= 70 degrees in each eye, able to recognize colors of traffic signals (red, amber, green)
(3) force whispered test >= 5 feet in better ear OR does not have average hearing loss > 40 decibels at 500, 1,000, and 2,000 Hz
(4) no loss of foot, leg, hand, or arm OR has been granted a skill performance evaluation
(5) insulin-treated diabetes is stable and diabetes controlled
(6) no current diagnosis of epilepsy OR has epilepsy exemption
(7) no current diagnosis of alcoholism

153
Q

4 absolutes

A

vision, hearing, insulin-treated diabetes, and epilepsy

154
Q

Mental/physical work demands of CDL drivers

A

attention/concentration/memory, visual spatial function, behavior, impulse control, communication/calculations

155
Q

Types of routes

A

(1) Turn around/short relay - driver returns home each evening
(2) Long relay - drives 9 to 11 hours, followed by >= 10 hours off-duty
(3) Straight through haul/cross country - driver may spend a month on the road, sleeps in truck, returns home for 4 to 5 days (team operation - drivers share driving: 5 hours on/off)

156
Q

Hours of service limits

A

70 hours/week
Passenger-carrying: 10 hours
Property-carrying: 14 hours

157
Q

Hearing measures

A

Pitch: Hz (500 to 2,000)
Loudness: decibels (dB)

158
Q

Disqualifying visual conditions

A

Monocular vision (can apply for exemption but ophthalmologist must provide approval)
Contact lenses when 1 corrects for distant visual acuity and the other for near visual acuity
Use of telescopic lenses
Failure to meet vision test in 1 or both eyes

159
Q

Field of vision

A

Normal (full binocular): 180 degrees
Normal (monocular): 160 degrees
Requirement: >= 70 degrees in both eyes

160
Q

Retina

A

Back of eyeball, sensitive to light
Rods: work in dim light
Cones: work in brighter light

161
Q

Diplopia

A

double vision - needs specialist assessment

162
Q

Cardiovascular disease disqualifications

A 
ECG: ischemic changes at rest
Echo: EF < 40%
Exercise tolerance test: cannot pass at >= 6 METs
Symptomatic disease
Resting angina
Poor medication tolerance
163
Q

Exercise tolerance test (ETT)

A

> = 6 METs (through Bruce Stage II or equivalent)
Attain HR > 85% predicted maximum (adjust for use of beta blockers)
Rise in SBP >= 20 mmHg without angina
No significant ST segment depression

164
Q

Idiopathic cardiomyopathy

A

Certify: 1 year (asymptomatic, LVEF > 40%, no ventricular arrhythmia)
Recertification: annual (with cardiology evaluation that includes Echo and Holter monitor)

165
Q

Left ventricular ejection fraction (LVEF)

A 
< 40% - disqualify
>= 40% and asymptomatic:
Waiting period: 1 month
Certify: 1 year
Recertification: annual (by cardiologist)
166
Q

Aortic stenosis

A

Mild: certify if asymptomatic (Echo q 5 years)
Moderate: wait 3 months after surgery (Echo annually)
Severe: disqualify unless 3 months post-surgery

167
Q

Severe aortic regurgitation

A

Do not certify if symptomatic, fails ETT, EF < 50%, or LVEDD >50/LVESD > 55 mm

EF >= 50%, LVEDD < 60/LVESD < 50 mm
Certify: 6 months (Echo q 6-12 months)

LVEDD = 60/LVESD = 50 mm
Certify: 4-6 months (Echo q 4 months)

168
Q

Mitral regurgitation

A

Do not certify if symptomatic
Mild: certify 1 year
Moderate: certify 1 year if normal LV
Severe: certify 1 year if asymptomatic (Echo q 6-12 months)

169
Q

MCSA-5870

A

Form that must be completed by treating clinician for insulin-dependent diabetes exemption (driver must provide electronic glucose records for at least 3 months)

170
Q

severe non-proliferative diabetic retinopathy/proliferative diabetic retinopathy

A

permanent disqualification

171
Q

Cervical range of motion

A

Flexion: 50 degrees
Extension: 60 degrees
L/R lateral extension: 45 degrees
L/R rotation: 80 degrees

172
Q

lumbar spine range of motion

A

Flexion: 60 degrees
Extension: 25 degrees
L/R lateral extension: 25 degrees

173
Q

Use of oxygen

A

Not permitted while driving

174
Q

Mallampati Score

A

Used to assess risk of sleep apnea:
I - soft palate, uvula, fauces, and pillars visible
II - soft palate, part of uvula, and fauces visible
III - soft palate and base of uvula visible
IV - only hard palate visible

175
Q

Spirometry

A

perform on all smokers > 35 years old, Hx of lung cancer, symptomatic (SOB, cough, chest tightness, wheezing)

176
Q

Spirometry findings

A

Low Forced Expiratory Volume in 1 second (FEV1) = air expelled in 1 second => obstructive diseases (emphysema, asthma, COPD)

Low Forced Vital Capacity (FVC) = total air expelled => restrictive diseases (asbestosis, sarcoidosis, pulmonary fibrosis)

177
Q

Pulmonary function findings

A

Pulse ox >= 92%
FEV1 > 65%
FVC > 60%
FEV1/FVC > 60%

178
Q

Arterial Blood Gases (ABGs)

A 
Order if pulse ox < 92%
Do not certify if:
PaO2 < 65 at altitude < 5,000 feet
PaO2 < 60 at altitude >= 5,000 feet
PaCO2 > 45 at any altitude
179
Q

Obstructive sleep apnea (OSA)

A

Mild = 5-14 episodes/hour
Moderate = 15-29 episodes/hour
Severe >= 30 episodes/hour

Moderate-to-severe OSA = apnea-hypopnea index >= 15

Waiting period: 1 month after starting CPAP treatment/3 months after surgical repair
Certify: 1 year (annual sleep study required, need to provide evidence of >= 70% adherence to CPAP use for >= 4 hours/night)
Recertification: annual

180
Q

Sleep apnea - definition

A

pause in breathing of >= 10 seconds

181
Q

Hypopnea

A

> = 50% airflow reduction for >= 10 seconds

182
Q

Abdominal Aortic Aneurysm (AAA)

A

do not certify if symptomatic, driver has recommendation for repair, 4-5 cm without clearance, OR > 0.5 cm increase over a 6-month period, regardless of original size

< 4.0 cm - certify 1 year with annual recertification (if asymptomatic)
4.0-5.0 cm - certify 1 year with annual recertification (if cleared by cardiologist)
> 5.0 cm - case-by-case (generally disqualify)

183
Q

Reinstatement following DUI conviction

A

Evaluation by substance abuse professional (SAP)
Documentation of SAP program
Negative drug/alcohol tests

184
Q

Traumatic brain injury (TBI)

A

Mild: does not penetrate dura and loss of consciousness (LOC) < 30 minutes - if seizure free and not taking anticonvulsants (certify 1 year with annual recertification)
Moderate: does not penetrate dura but LOC 30 min. to 24 hrs. - waiting period of 4 years
Severe: penetrates dura and LOC > 24 hrs. - permanent disability

185
Q

Headaches

A

not disqualifying except chronic migraine OR unless accompanied by neurological deficits
headaches with atypical facial pain and vision loss could be a CNS tumor - refer to specialist to rule out

186
Q

Mental health disorders

A

Refer for additional evaluation: bipolar disorder, major depressive disorder, obsessive compulsive disorder, antisocial personality disorder

187
Q

Driver qualifications (federal standards)

A 
>= 21 years of age
read and speak English
safely operate vehicle
physically qualified (ME decision)
current/valid CDL/CLP
has provided employer a list of violations
is not disqualified to drive
has passed road test
188
Q

Waivers vs. exemptions

A

Only the FMCSA can grant waivers or exemptions - not the ME
Waivers - provide relief from regulations for up to 3 months
Exemptions - provide relief up to 2 years

189
Q

Aortic valve repair

A

Waiting period: 3 months after surgery
Certify: 1 year (asymptomatic, LVEF > 50%, no blood clots, ECG q 5 years, 2D ECG with Doppler prior to hospital discharge)
Recertification: annual (by cardiologist)

190
Q

Urinalysis - reference ranges

A
  • Required component of exam - reference ranges:
  • color: yellow (light to amber)
  • clarity: clear
  • pH: 4.5-8
  • specific gravity: 1.005-1.025*
  • glucose: <= 130*
  • blood: <= 3 RBCs*
  • protein: <= 150*
  • bilirubin: negative
191
Q

Blepharitis

A

Anterior: affects outer edge of eyelid
Posterior: affects inner edge (part that touches the eyeball)

192
Q

Hearing loss

A

if identified by ME, should be referred to specialist before final determination

193
Q

Levels of hearing loss

A

dBs: 0-25 normal hearing
dBs: 26-40 mild hearing loss (difficulty with distance speech)
dBs: 41-55 moderate hearing loss (difficulty with conversational speech)
dBs: 56-70 moderately severe hearing loss (difficulty with group conversations)
dBs: 71-90 severe hearing loss (difficulty with loud speech)
dBs: >= 91 profound hearing loss

194
Q

Auditory brain stem response

A

place electrodes on each earlobe and scalp, headphones worn, clicking noises generated - tests each ear separately

195
Q

Stress tests - intake restrictions

A
  • Do not eat or drink anything with caffeine for 12 hours prior
  • Do not eat or drink anything but water 4 hours prior
196
Q

Phosphorus

A

Normal: 3-4.5 mg/dL

197
Q

Chemistry screen

A

type of blood test

198
Q

Types of blood thinners

A

(1) anticoagulants: work on chemical reactions in the body to increase the time it takes for blood clots to form
(2) antiplatelets: prevent blood cells from clumping together

199
Q

Recommendations for shift work

A

Get >= 6 hours of consecutive sleep (try different sleep times)
Avoid permanent night shifts
Have planned time off
Avoid quick shift changes
Minimize number of consecutive overnight shifts
Take a nap beforehand (no more than 20-30 minutes)

200
Q

Types of ejection fraction

A

Normal: 50-70%
EF < 40% is too low (41-49% is borderline) = HF
EF > 70% = hypertrophic cardiomyopathy
(1) preserved (diastolic HF due to increased ventricular filling pressure - ventricles contract normally but do not relax and muscle becomes stiff)
(2) reduced (systolic heart failure/cardiomyopathy - heart muscle does not contract effectively, decreasing the force of blood flow)

201
Q

Medical certification required

A
  • combined vehicle weight >= 10,001 pounds
  • vehicle used to transport 9-15 passengers (including the driver) for compensation
  • vehicle used to transport >= 16 passengers (whether for compensation or not)
  • transporting hazardous materials in quantity requiring a placard
202
Q

Code of Federal Regulations (49CFR391.41)

A

Title 49 = Transportation
Part 391 = Driver Qualifications
Section 41 = physical qualifications of driver

203
Q

Part 391 sections

A

40 - alcohol/drug testing procedures
41 - physical qualifications of drivers
43 - responsibilities of ME
45 - who must have a CMV medical exam
47 - conflict resolution
49 - Skills Performance Evaluation program
62 - limited exemptions for intra-city zone drivers
64 - grandfathering: vision and DM waivers

204
Q

Cataracts

A

opacification of lens
S/S: glare with night driving, decreased acuity/contrast/color resolution
Tx: surgery

205
Q

Glaucoma

A

abnormal regulation of intraocular pressure (IOP)
Types:
(1) normal/low tension - optic nerve damage (refer to specialist)
(2) open-angle (most common) - slow clogging of drainage canals leads to increased IOP
*(3) angle-closure (most dangerous) - closing of angle leads to sudden increase in IOP
S/S: deficits in peripheral vision, seeing halos around lights, hazy looking eyes, nausea, tunnel vision, redness in eyes
Tx: eye drops - vision lost cannot be restored

206
Q

Macular degeneration

A

damage to the macula
Types:
(1) dry (85-90% of cases) - deterioration of retina due to deposit of drusen under macula
*(2) wet (most dangerous) - abnormal blood vessels grow under retina and macula (bleed and leak fluid)
S/S: loss of central vision, scotoma (dark spots) in direction of attempted gaze
Tx: none - vision lost cannot be restored

207
Q

Retinopathy

A

damage to the small blood vessels in the eye
Types:
(1) non-proliferative (blood vessels not growing)
*(2) proliferative (abnormal blood vessels growing in size)
S/S: partial scotoma, spots, hemorrhages, exudates (white spots due to fatty deposits), cotton wool spots (microstrokes), abnormal blood vessels, aneurysms

208
Q

Pulmonary HTN

A

pulmonary artery pressure > 50% of systemic SBP

209
Q

6 METs

A

workload requirements for heavy and very heavy work

210
Q

Sudden death

A

individual goes from usual state of health to death within 1 hour

211
Q

Pre-syncope

A

lightheadedness, dizziness

212
Q

Respiratory assessment - when to send to specialist

A

send to pulmonologist if clubbing, cyanosis, tachypnea at rest, or friction rub

213
Q

Heart murmur grades

A 
I strain to hear
II faint without straining
III loud
IV loud with thrill
V heart with stethoscope on skin
VI heard with stethoscope off skin
214
Q

Aortic regurgitation - left ventricular dimensions

A

Left ventricular end-diastolic dimension: <= 60 mm

Left ventricular end-systolic dimension: <= 50 mm

215
Q

3 peripheral nervous systems

A

(1) vestibular - balance
(2) visual - vision
(3) proprioception - positional awareness

216
Q

Hernias

A

Check abdomen, viscera, and GU system - refer for specialist evaluation

217
Q

Drug testing (urinalysis)

A

tests for: marijuana, cocaine, amphetamines, opiates, phencyclidine (PCP)

218
Q

Becker’s muscular dystrophy

A

onset as late as 25, causes heart problems, allows normal walk

219
Q

Myotonic/Steinert’s muscular dystrophy

A

most common - causes muscle weakness

220
Q

Duchene’s muscular dystrophy

A

disqualifying - more common in boys, onset in childhood

221
Q

Limb-girdle muscular dystrophy

A

affects men and women, causes weakness in hips that moves to limbs, becomes difficult to walk after 20 years

222
Q

Pericardial effusion

A

fluid in the sac around the heart

223
Q

Venous thromboembolism

A

blood clots that form in a vein

224
Q

Intracerebral hematoma

A

hematoma found in brain tissue

225
Q

Reporting head injuries

A

any head injury that occured in the past 5 years - any severe TBI must be reported regardless of when it occurred

226
Q

Clubbing edema

A

signs of vascular, lung, or heart disease

227
Q

Middle ear infection

A

inflammation in middle ear - treat prior to certification (problems with inner ear require specialty consult, even if hearing test passed)

228
Q

Nitrogylcerine

A

not a disqualifying indication

229
Q

Abnormal Babinski reflex

A

splaying of toes - sign of brain or spinal chord disorder

230
Q

Pulse ox

A

measures O2 concentration in the blood - tested using oximeter (photoelectric device)

231
Q

Pure tone audiometry

A

uses pitch and loudness to test hearing - vibrating device is placed on the bone behind the ear and driver listens to tones through headphones (tests each ear separately)

232
Q

Amaylase

A

Normal: 53-123 (can be elevated in pancreatitis and alcoholism)

233
Q

Toxicology exams

A

Blood, urine, or saliva
can test for 30 drugs at once
can test for illicit drugs, prescription medications, vitamins, and alcohol

234
Q

Multiple sclerosis - S/S

A

visual disturbances, muscle weakness, memory problems, numbness

235
Q

S/S of CHF

A 
SOB on exertion (or at rest)/wheezing
need to urinate at night
edema (ankles/abdomen)
JVD/prominent neck veins
bluish discoloration of face
abnormal heart sounds
weight gain/fatigue
236
Q

Hx of TIA on anticoagulants

A

disqualify

237
Q

Oculopharyngeal muscular dystrophy

A

affects individuals aged 40-60, affects eyes and throat, progresses slowly

238
Q

Conjuntivitis

A

inflammation, gritty feeling in eyes, swollen eyelids, excessive tearing

239
Q

Health Hx

A

ME must discuss any “Yes” answers and document the discussion (Hx, Dx, Tx, and response to Tx; etiology; tests/consultations ordered)
failure to fill out fully and honestly can invalidate the exam - must include any condition under treatment for or any illness, condition, or injury sustained in the last 5 years

240
Q

Components of ABGs

A

pH: normal (7.35-7.45) - measure of acid content (H+ ions) in the blood
PaCO2: normal (35-45) - measure of CO2 level in the blood
HCO3- (bicarbonate): normal (22-26) - chemical buffer that keeps the pH from becoming too acidic/basic
PaO2: normal (> 60%) - amount of dissolved O2 in the blood (indicates how well O2 can move from airspace to the blood)
SaO2: normal (95-100%) - number of hemoglobin binding sites that have O2 attached

241
Q

Digoxin

A

used for treatment of irregular HR - ideal range: 1.5-2.5 ng/dL
S/S of digoxin toxicity: confusion, dizziness, nausea, yellow tinted vision, blurred vision

242
Q

Side effects of antipsychotic medications

A

weight gain, increased risk of diabetes, restlessness, tardive dyskinesia, muscle spasms, tremors

243
Q

Exemption from medical certification exam

A
  • driver is subject to Part 391 but company is private, non-business motor carrier of 9-15 passenger van
  • school bus drivers (driving between school and home)
  • transporting personal property
  • transporting corpses/sick/injured people
  • transporting to races/tournaments/shows, if not done for profit
  • fire trucks/rescue vehicles involved in emergency operations
  • transporting propane/winter heating fuel or responding to pipeline emergency
  • responding to emergency in declared disaster
  • driving off-road motorized construction vehicles
244
Q

Driver fails exam but still holds unexpired medical card

A

card is no longer valid

245
Q

Pending status exam

A

must be completed within 45 days or the exam must be redone - not an option for intrastate operations

if certification decision is made before the 45-day waiting period, expiration date of new certificate is based on the certification decision, not the date of the exam

246
Q

Driver privacy

A

Carriers cannot:

  • store any medical records in personnel file
  • disclose any medical information to co-workers
247
Q

Use of anti-hypertensives

A

driver is still considered to have HTN, even in BP controlled

248
Q

Cardiomyopathy

A

heart chambers enlarge so that heart cannot beat with as much force

249
Q

Disqualifying cardiovascular conditions

A
  • ICD (including pacemaker/ICD)
  • thoracic aneurysm > 3.5 cm
  • AAA > 5 cm
  • untreated aneurysms
  • untreated DVT
  • pain at rest from vascular disease or intermittent claudication
  • unstable angina
  • hypertrophic/restrictive cardiomyopathy
  • heart conditions that cause fainting
250
Q

Superficial phlebitis

A

inflammation of vein wall - can be certified for 2 years if no coexisting DVT

251
Q

Supraventricular arrhythmias

A

irregular heart rate originating above the ventricles

(1) supraventricular tachycardia - cured through catheter ablation
(2) A-fib - wait 1 month after adequate anticoagulant treatment

252
Q

Echocardiography (Echo)

A

creates an image of the heart using ultrasound - superior to ETT

253
Q

Unstable angina

A

unpredictable pattern, pain at rest, change in pattern, decreased response to medications - do not certify

254
Q

Tuberculosis - certification by type of test

A

+ intermediate TB skin test = previous infection (can certify)

+ purified protein derivative (PPD) skin test and normal CXR (can certify)

+ PPD with abnormal CXR (requires further evaluation)

255
Q

Disqualifying diabetes complications

A
  • hypoglycemic reaction in the last 12 months
  • > =2 hypoglycemic reactions in the last 5 years
  • loss of positional sensation
  • loss of sensation in feet
  • resting tachycardia
  • orthostatic hypotension
  • Dx of peripheral neuropathy or proliferative retinopathy
256
Q

Keratoconus

A

eye disease that affects the structure of the cornea - tissue on the front of the eye (cornea) thins and bulges outward into a cone shape
S/S: increased light sensitivity, eye strain, halos around lights, excessive eye rubbing, headaches

257
Q

Keratitis

A

inflammation of the cornea

S/S: difficulty opening eyelid, redness, eye pain, blurred or reduced vision, photophobia, tearing

258
Q

Hyperopia

A

farsightedness - can see distant objects clearly but near objects are blurry

259
Q

Facioscapulohumeral muscular dystrophy

A

affects men and women; progresses slowly; affects face, upper arm, shoulder; causes difficulty swallowing and walking

260
Q

Amblyopia

A

lazy eye - decreased vision in one eye (lazy eye wanders inward or outward)
S/S: favoring one eye, bumping into objects on one side
not automatically disqualifying

261
Q

Distal muscular dystrophy

A

affects forearms, hands, lower legs, and feet; affects muscles farthest from the center of the affected area; progresses slowly

262
Q

Dermatological and GI conditions

A

if they do not affect driving, driver does not necessarily have to report but must report drugs used to treat
Certify for 1 year

263
Q

Distended neck veins

A

indicative of a vascular or heart disorder - refer to specialist

264
Q

Carpal tunnel syndrome

A

type of peripheral neuropathy - disqualify

265
Q

Contact lenses

A

Certify if well tolerated - disqualify if excessive tearing

266
Q

Speech and word recognition test

A

hearing test of ability to hear and understand normal conversation - driver asked to repeat simple words spoken at different degrees of loudness

267
Q

Cholesterol

A

Total: < 200 (borderline: 201-240; high > 240)
LDL: < 160 (optimal < 100)
HDL: 45-70 (men); 50-90 (women)
Triglycerides: < 150 (borderline 150-199; high > 200)

268
Q

Severe side effects of antiplateletes

A

blood in urine, chest pain, SOB, difficulty swallowing, severe stomach pain

269
Q

Side effects of anti-anxiety medications

A

drowsiness, sleep disturbance, blurred vision, nightmares

270
Q

Tarps

A
  • use all eyelets to tie down
  • blue with UVV protection and 12 mm thickness (can last > 10 years)
  • 6 mm thick (can last 3-5 years)
  • water collected on tarp can strain eyelets and lead to tears
271
Q

5th wheel

A

must be tilted up prior to coupling

272
Q

Steps to Certification for Insulin-dependent DM

A
  1. follow treatment plan developed with clinician (keep at least 3 months of electronic glucose readings)
  2. schedule appointment with treating clinician and bring glucose records
  3. treating clinician completes and signs MCSA-5870
  4. have medical exam within 45 days of the MCSA-5870 being completed
  5. repeat steps 1-4 annually
273
Q

Medical Certification under ITDM program

A

do NOT mark “Accompanied by a ____ waiver/exemption” under Section 391.46 (section does not involve a waiver or exemption program)

274
Q

Three categories of risk associated with psychological disorders

A

mental disorder itself, lingering symptoms, medications

275
Q

Bipolar disorder/major depression

A

Waiting period: 6 months (non-psychotic major depression that is not accompanied by suicidal behavior); 1 year (severe depressive episode, suicide attempt, manic episode)
Certify: 1 year (report any manic or severe depressive episode within 30 days)
Recertification: annual (clearance by mental health professional every 2 years)

276
Q

Personality disorders

A

Waiting period: as necessary until the cause is confirmed and treatment is adequate
Certify: 1 year
Recertification: annual

277
Q

Schizophrenia

A

Disqualify for chronic schizophrenia
Waiting period: at least 6 months symptom free (if brief reactive psychosis or schizophreniform disorder); 1 year (any other psychotic disorder)
Certify: 1 year
Recertification: annual (evaluation every 2 years by mental health specialist)

278
Q

Drug abuse

A

drivers may never use Schedule I drugs, amphetamines, narcotics, methadone, or marijuana - even if prescribed by treating clinicians

279
Q

MCSA-5895

A

391.41 CMV Driver Medication Form - can be requested by ME from the treating clinician in cases of suspected substance misuse

280
Q

Suspected alcohol use

A

contact driver’s employer for information on reasonable suspicion drug and alcohol testing - examiner cannot order a test but can perform a non-DOT test using a non-DOT form - driver is not required to obtain a new physical exam after completing SAP program

281
Q

Drug abuse

A

Waiting period: driver must be evaluated by SAP, comply with recommended rehabilitation program, and have a negative result on a return to duty drug test
Certify: 2 years (use of 12 step programs is insufficient as SAP program, but is not disqualifying)
Recertification: biennial

282
Q

Scheduled drugs

A

I - have no currently accepted medical use, cannot be legally prescribed, have high abuse potential, not considered safe (heroin and marijuana)
II - have accepted medical uses but high abuse potential (methadone)
III-V decreasing risk for abuse (III includes tranquilizers, IV includes chlorhydrol and phenobarbital, V includes narcotic compounds)

283
Q

Resolving conflicts (2 MEs disagree on driver qualifications)

A

driver must see an impartial medical specialist in the field in which the conflict arose
driver or employer submits a written application to the FMCSA (driver remains disqualified until the FMCSA makes a decision)

284
Q

Medical certification requirements

A

ME is responsible for making medical determinations on fitness for duty
Employer is responsible for informing ME of minimum physical requirements and characteristics of work being performed

285
Q

Drug urine testing

A

60 ml of urine required to perform testing - any remaining urine can be used to test for glucose or protein levels

286
Q

Medical exam requirements after an illness

A

a new test is not required unless the illness impaired the driver’s ability to perform normal duties

287
Q

Geographic setting of medical exams

A

ME can be located in a different state than the one in which the driver is licensed or lives

288
Q

Inaccurate Health Hx section

A

deliberate omission of falsification may invalidate exam - civic penalty may be issued against the driver for making a false statement of - or concealing - a disqualifying medical condition

289
Q

Driver performing a road test

A

requires a valid medical card and driver’s license or permit

290
Q

Short-term medical card

A

requires a new medical exam prior to expiration (card expires on stated date - 30 days, 6 months, etc.)

291
Q

Determination Pending status

A

Driver is still eligible to drive but requires a determining within 45 days or else the certification expires (only if the driver currently holds a valid medical certificate)

292
Q

Disqualifying exam with valid medical certification

A

new exam invalidates prior exam (old card is invalid if driver fails a medical exam, even if prior card had not expired)

293
Q

Provigil (Modafinil)

A

Used to treat excessive sleepiness (narcolepsy, OSA, shift work disorders)
Waiting period: 6 weeks
Certify: 1 year (disqualifying if being used to treat narcolepsy)
Recertification: annual

Certified Medical Examiner - FMCSA (1 decks)

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