Medical Examination Report — Mr. John Doe
Gender: Male | Age:48 | Height: 67” | Weight: 200 lbs.
Health History Yes response(s): Heart disease or heart attack – history of CABG 3 years prior, no recurrent symptoms until two weeks ago. Last cardiac stress test: following CABG 3 years ago. Currently seeing a cardiologist for a single episode of chest pain that occurred two weeks ago while rooﬁng his home. Chest pain: lasted a half hour, gradually resolved without treatment.
- Located primarily in the left pectoral area, not radiating, and aggravated by movement of the left arm. “Felt like a charley horse” with mild residual soreness present for about 24 hours.
- Consulted with primary care provider who referred Mr. Doe to a cardiologist. Mr. Doe provided a copy of the cardiologist’s report.
- Cardiologist reports normal EKG.
- Scheduled lab work and stress test/echocardiogram in two weeks.
- No medications prescribed and no activity restrictions.
- No recurrence of the chest pain.
- Mr. Doe is a nonsmoker, has no hyperlipidemia history.
- Father had an MI at age 49.
Medication(s): Aspirin daily.
Blood Pressure/Pulse BP-112/70 P-84 & Regular
Physical Examination: Normal except CABG scar.
What is the certiﬁcation decision in this scenario? The Medical Examiner (ME) made a decision of Determination Pending. The ME noted that he agreed with the cardiologist that the risk of current cardiovascular disease is low but given the recent history of atypical chest pain and history of CABG there is insufﬁcient information to make a long term certiﬁcation determination. Conversely, the ME noted that given that the characteristics of the described chest pain are atypical, and the risk of a sudden incapacitating event is low, so temporary disqualiﬁcation is not indicated.
The ME had the driver complete HIPAA compliant information release forms and requested records from the treating cardiologist and primary care physicians and sent letters to the treating providers requesting medical clearance for CMV driving, including documentation related to CMV driving duties.
The ME explained the Determination Pending decision to the driver. The driver’s current medical certiﬁcate expires in 5 weeks, and the ME notiﬁed the driver that if the certiﬁcations from the treating providers are not received, including the results of the cardiac stress testing, then the driver’s certiﬁcate will expire and the driver will be medically disqualiﬁed until he has another certiﬁcation examination.
The ME discussed employer notiﬁcation issues with the driver. The driver noted that he had already notiﬁed his employer of the recent medical issues and indicated that his employer was also aware of his history of CABG. The ME asked the driver to sign a HIPAA compliant information release and then contacted the driver’s employer and notiﬁed them of the results of the examination and explained the Determination Pending issues. If the driver had not consented to employer notiﬁcation of the details of his history and examination, the ME would have only provided the Medical Examiner’s Certiﬁcate to the employer.
The cardiovascular standard requires the driver “have no current clinical diagnosis of myocardial infarction, angina pectoris, coronary insufﬁciency, thrombosis, or any other cardiovascular disease of a variety known to be accompanied by syncope, dyspnea, collapse, or congestive cardiac failure.” Neither the primary care provider or cardiologist examinations of Mr. Doe conﬁrmed a diagnosis of current cardiovascular disease.
It is not the role of the Medical Examiner to diagnose and treat the driver; however, the Medical Examiner decides whether the nature and severity of the condition is such that the driver is at a high risk for sudden incapacitation. The physical examination was unremarkable, and Mr. Doe had resumed normal activities prior to examination.