Guide for AME’s | Ch. 3 Pg. 35 – Pilot Medical Solutions

EXAMINATION TECHNIQUES AND CRITERIA FOR QUALIFICATION
Items 21-48 of FAA Form 8500-8

The Examiner must personally conduct the physical examination. This chapter provides guidance for completion of Items 21-48 of the Application for Airman Medical Certificate or Airman Medical and Student Pilot Certificate, FAA Form 8500-8.

The Examiner must carefully read the applicant’s history page of FAA Form 8500-8 (Items 1-20) before conducting the physical examination and completing the Report of Medical Examination. This will alert the Examiner to possible pathological findings.

ITEMS 21-22. Height and Weight

21. Height

Record the applicant’s height in inches. Although there are no medical standards for height, exceptionally short individuals may not be able to effectively reach all flight controls and must fly specially modified aircraft.

If required, the FAA will place operational limitations on the pilot certificate.

22. Weight

Record the applicant’s weight in pounds.

ITEMS 23-24. Statement of

Demonstrated Ability (SODA); SODA Serial Number

Ask the applicant if a SODA has ever been issued. If the answer is “yes”, ask the applicant to show you the document. Then check the “yes” block and record the nature and degree of the defect.

SODA’s are valid for an indefinite period or until an adverse change occurs that results in a level of defect worse than that stated on the face of the document.

The FAA issues SODA’s for certain static defects, but not for disqualifying conditions that may be progressive. The extent of the functional loss that has been cleared by the FAA is stated on the face of the SODA, and if the Examiner finds the condition has become worse, a medical certificate should not be issued even if the applicant is otherwise qualified. The Examiner should also defer issuance if it is unclear whether the applicant’s

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present status represents an adverse change.

The Examiner must take special care not to issue a medical certificate of a higher class than that specified on the face of the SODA even if the applicant appears to be otherwise medically qualified. The Examiner may note in Item 60 the applicant’s desire for a higher class.

24. Soda Serial Number

Enter the assigned serial number in the space provided.

ITEMS 25-30. Ear, Nose, and Throat (ENT)

I. CODE OF FEDERAL REGULATIONS

All Classes: 14 CFR 67.105(b)(c), 67.205(b)(c); and 67.305(b)(c)

***No disease or condition of the middle or internal ear, nose, oral cavity, pharynx, or larynx that—

Interferes with, or is aggravated by, flying or may reasonably be expected to do so; or

Interferes with, or may reasonably be expected to interfere with, clear and effective speech communication.

***No disease or condition manifested by, or that may reasonably be expected to be manifested by, vertigo or a disturbance of equilibrium.

II. EXAMINATION PROCEDURES

A. Equipment

It will be necessary to have at least an otoscope, a nasal speculum, tongue blades, and laryngeal mirror. The otoscope light can serve as a transilluminator. Some Examiners may find that a solution of 1/4 percent phenylephrine hydrochloride and cotton swabs is sometimes useful. Examiners trained in the use of a head mirror and wire ear loop may also find these useful for the removal of cerumen.

Conditions that call for evaluation with a nasopharyngoscope, cannula, curette, irrigation device, or suction device may best be referred to an ENT specialist.

B. Examination Techniques

1. The head and neck should be examined to determine the presence of any significant defects such as:

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a. Bony defects of the skull.

b. Gross deformities.

c. Fistulas.

d. Evidence of recent blows or trauma to the head.

e. Limited motion of the head and neck.

f. Surgical scars.

2. The external ear is seldom a major problem in the medical certification of airmen. Otitis externa or a furuncle may call for temporary disqualification. Obstruction of the canal by impacted cerumen or cellular debris may indicate a need for referral to an ENT specialist for examination.

The tympanic membranes should be examined for scars or perforations. Discharge or granulation tissue may be the only observable indication of perforation. Middle ear disease may be revealed by retraction, fluid levels, or discoloration. The normal tympanic membrane is movable and pearly gray in color. Mobility should be demonstrated by watching the drum through the otoscope during a valsalva maneuver.

3. Pathology of the middle ear may be demonstrated by changes in the appearance and mobility of the tympanic membrane. The applicant may only complain of stuffiness of the ears and/or loss of hearing. An upper respiratory infection greatly increases the risk of aerotitis media with pain, deafness, tinnitus, and vertigo due to lessened aeration of the middle ear from eustachian tube dysfunction. When the applicant is taking medication for an ENT condition, it is important that the Examiner become fully aware of the underlying pathology, present status, and the length of time the medication has been used. If the condition is not a threat to aviation safety, the treatment consists solely of antibiotics, and the antibiotics have been taken over a sufficient period to rule out the likelihood of adverse side effects, the Examiner may make the certification decision.

The same approach should be taken when considering the significance of prior surgery such as myringotomy, mastoidectomy, or tympanoplasty. Simple perforation without associated symptoms or pathology is not disqualifying. When in doubt, the Examiner should not hesitate to defer issuance and refer the matter to the Aeromedical Certification Division. AAM-300. The services of consultant ENT specialists are available to the FAA to help in determining the safety implications of complicated conditions. (For details concerning otosclerosis surgery, see Item 49).

4. The nose should be examined for the presence of polyps, blood, or signs of infection or allergy. The Examiner should determine if there is a history of epistaxis with exposure to high altitudes and if there is any indication of loss of sense of smell (anosmia). Polyps may cause airway obstruction or sinus blockage. Infection or allergy may be cause for obtaining additional history. Anosmia is at least noteworthy in that the airman should be made fully aware of the significance of the handicap in

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flying (inability to receive early warning of gas spills, oil leaks, or smoke). Further evaluation may be warranted.

5. Evidence of sinus disease must be carefully evaluated by a specialist because of the risk of sudden and severe incapacitation from barotrauma.

6. The mouth and throat should be examined to determine the presence of active disease that is progressive or may interfere with voice communications. Gross abnormalities that could interfere with the use of personal equipment such as oxygen equipment should be identified.

7. The larynx should be visualized if the applicant’s voice is rough or husky. Acute laryngitis is temporarily disqualifying. Chronic laryngitis requires further diagnostic workup. Any applicant seeking certification for the first time with a functioning tracheostomy, following laryngectomy, or who uses an artificial voice-producing device should be deferred or denied and carefully assessed.

III. DISPOSITION

The following is a partial list of conditions that warrant denial or deferral to the Aeromedical Certification Division, AAM-300. All disqualifying defects are subject to further FAA consideration. In any of the acute conditions listed, issuance may be postponed for up to 2 weeks pending resolution.

A. ITEM 25. Head, face, neck, and scalp

1. Fistula of neck, either congenital or acquired, including tracheostomy.

2. Loss of bony substance involving the two tables of the cranial vault.

3. Deformities of the face or head that would interfere with the proper fitting and wearing of an oxygen mask (FAA certification is possible with operational limitations).

B. ITEM 26. Nose

1. Evidence of severe allergic rhinitis.

2. Malformations that would prevent nasal respiration.

3. Obstruction of sinus ostia, including polyps, that would be likely to result in complete closure under conditions to which airmen are exposed.

C. ITEM 27. Sinuses

1. Sinusitis, acute or chronic.

2. Tumor.

D. ITEM 28. Mouth and throat

1. Palate: Extensive adhesion of the soft palate to the pharynx.

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2. Any malformation or condition, including stuttering, that would impair voice communication. (See Item 47).

E. ITEM 29. Ears, general

1. Inner ear: Acute or chronic disease that may disturb equilibrium.

2. Mastoids:

a. Mastoiditis, acute or chronic.

b. Mastoid fistula.

3. Middle ear:

a. Otitis media, serous or suppurative, acute or chronic.

b. Impaired aeration.

4. Outer ear:

a. Otitis externa that may progress to impaired hearing or become incapacitating.

b. Impacted cerumen until removed.

F. ITEM 30. Ear Drums

Any perforation that has associated pathology is disqualifying for all classes.

Some ENT conditions known only through history may also be disqualifying — see, for example, Item 18 (Medical History).

Some conditions may have several possible causes or exhibit multiple symptomatology. An example would be disturbance in equilibrium. Although ENT conditions are a possible cause, the principal discussion of these conditions is found in the neurological sections. (See Item 46).

ITEMS 31-34. EYE

I. CODE OF FEDERAL REGULATIONS
All Classes: 14 CFR 67.103(e); 67.203(e), and 67.303(d)

***No acute or chronic pathological condition of either eye or adnexa that interferes with the proper function of an eye, that may reasonably be expected to progress to that degree, or that may reasonably be expected to be aggravated by flying.

(For further evaluation of the eyes, see Items 50-54).

II. EXAMINATION PROCEDURES

A. Equipment

For evaluation of the eye, the Examiner needs a quality

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ophthalmoscope and a moderate intensity point light source.

B. Examination Techniques

1. The examination of the eyes should be directed toward the discovery of diseases or defects that may cause a failure in visual function while flying or discomfort sufficient to interfere with safely performing airman duties.

2. It is recommended that the Examiner consider the following signs during the course of the eye examination:

a. Color — redness or suffusion of allergy, drug use, glaucoma, infection, trauma, jaundice, and the green or brown Kayser-Fleischer Ring of Wilson’s disease.

b. Swelling — abscess, allergy, cyst, exophthalmos, myxedema, tumor.

c. Other — clarity, discharge, dryness, ptosis, spasm (tic), tropion, ulcer.

3. Ophthalmoscopic examination. It is suggested that a routine be established for ophthalmoscopic examinations to aid in the conduct of a comprehensive eye assessment. Routine use of a mydriatic is not recommended.

a. Cornea — observe for abrasions, calcium deposits, contact lenses, dystrophy, keratoconus, pterygium, scars, or ulceration. Contact lenses should be removed several hours before examination of the eye. (See Item 50).

b. Pupils and Iris — check for the presence of synechiae and uveitis. Size, shape, and reaction to light should be evaluated during the ophthalmoscopic examination. Observe for coloboma, reaction to light, or disparity in size.

c. Aqueous — hyphema or rheumatoid iridocyclitis.

d. Lens — observe for aphakia, discoloration, dislocation, cataract, or an implanted lens.

e. Vitreous — note discoloration, hyaloid artery, floaters, or strands.

f. Optic nerve — observe for atrophy, cupping, or papilledema.

g. Retina and choroid — examine for evidence of coloboma, choroiditis, detachment of the retina, retinitis, retinitis pigmentosa, retinal tumor, senile macular or other degeneration, toxoplasmosis, etc.

4. Ocular Motility. Motility may be assessed by having the applicant follow a point light source with both eyes, the Examiner moving the light into right and left upper and lower quadrants while observing the individual and the conjugate motions of each eye. The Examiner then brings the light to center front and advances it toward the nose observing for convergence. End point nystagmus is a physiologic nystagmus and is not considered to be significant. It need

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not be reported. (See Item 50 for further consideration of nystagmus).

III. DISPOSITION

The following is a partial list of conditions that warrant denial or deferral to the Aeromedical Certification Division, AAM-300. All disqualifying defects are subject to further FAA consideration.

This section of the Guide applies to findings observed by the Examiner. Functional testing of the eyes is covered in Items 50 through 54 and medical history in Item 18.

A. ITEM 31. Eyes, general

1. Hereditary, congenital, or acquired conditions, whether acute or chronic, of either eye or adnexa, that may interfere with visual functions, may progress to that degree, or may be aggravated by flying (i.e., tumors and ptosis obscuring the pupil, acute inflammatory disease of the eyes and lids, cataracts, or orthokeratology).

2. Any condition not currently symptomatic but prone to become worse or recur with functional loss or acute symptoms that would be incapacitating or cause significant decrements in operational efficiency (i.e., retinal detachment, optic neuritis, chorioretinitis).

3. Any ophthalmic pathology reflecting a serious systemic disease (e.g., diabetic and hypertensive retinopathy).

B. ITEM 32. Ophthalmoscopic

1. Corneal ulcer or dystrophy.

2. Chorioretinitis; coloboma.

3. Retinal detachment; retinal degeneration; retinitis pigmentosa.

4. Papilledema; optic atrophy; optic neuritis.

5. Macular degeneration; macular detachment.

6. Vascular occlusion; retinopathy.

7. Tumors.

8. Glaucoma (treated or untreated).

C. ITEM 33. Pupils

1. Synechiae, anterior or posterior.

2. Nonreaction to light in either eye.

3. Disparity in size or reaction to light requires clarification and/or further evaluation

4. Nystagmus.

D. ITEM 34. Ocular motility

1. Paralysis with loss of ocular motion in any direction.

2. Absence of conjugate alignment in any quadrant.

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3. Inability to converge on a near object.

Applicants with many of the foregoing conditions may be found qualified for FAA certification following the receipt and review of specialty evaluations and pertinent medical records. Examples include retinal detachment with surgical correction, open angle glaucoma under adequate control with medication and narrow angle glaucoma following surgical correction.

The Examiner may not issue a certificate under such circumstances for the initial application, except in the case of applicants following cataract surgery. The Examiner may issue a certificate after cataract surgery for applicants who have undergone cataract surgery with or without lens(es) implant. If pertinent medical records and a current ophthalmologic evaluation (using FAA Form 8500-7 or FAA Form 8500-14) indicate that the applicant meets the standards, the FAA may delegate authority to the Examiner to issue subsequent certificates.

If there is a question regarding the need for a current specialty evaluation, the Examiner should not obtain the evaluation, but should instead transmit the completed application (FAA Form 8500-8) and forward any available medical records to the Aeromedical Certification Division, AAM-300.

ITEMS 35-37. CARDIOPULMONARY

I. CODE OF FEDERAL REGULATIONS

A. First-Class: 14 CFR 67.111(c)

***A person applying for first-class certification medical certification must demonstrate an absence of mycocardial infarction and other clinically significant abnormality on electrocardiographic examination:

At the first application after reaching the 35th birthday; and

On an annual basis after reaching the 40th birthday.

B. All Classes:

14 CFR 67.111(a), 67.211, and 67.311

***No established medical history or clinical diagnosis of —

Myocardial infarction;

Angina pectoris; or

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Coronary heart disease that has required treatment or, if untreated, that has been symptomatic or clinically significant.

Cardiac valve replacement

Permanent cardiac pacemaker implantation; or

Heart replacement

C. All Classes: 14 CFR 67.113(b)(c), 67.213(b)(c), and 67.313(b)(c)

***No other organic, functional, or structural disease, defect, or limitation that the Federal Air Surgeon, based on the case history and appropriate, qualified medical judgment relating to the condition involved, finds —

Makes the person unable to safely perform the duties or exercise the privileges of the airman certificate applied for or held; or

May reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the person unable to perform those duties or exercise those privileges;

***No medication or other treatment that the Federal Air Surgeon, based on the case history and appropriate, qualified medical judgment relating to the medication or other treatment involved, finds-

Makes the person unable to safely perform the duties or exercise the privileges of the airman certificate applied for or held; or

May reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the person unable to perform those duties or exercise those privileges.

(Also see Items 55, 56, and 58 for other information on the cardiovascular system).

II. EXAMINATION PROCEDURES

A. Equipment

For the conduct of the medical examination applicable to Items 35-37, the only necessary equipment is an examining table and a good stethoscope. History or current findings may indicate a need for special evaluations.

B. Examination Techniques

It is helpful to follow a set routine of examination. One approach is as follows:

1. Inspection. Observe and report any thoracic deformity (e.g., pectus excavatum), signs of surgery or other trauma, and clues to ventricular hypertrophy. Check the hematopoietic and vascular system by observing for pallor, edema, varicosities, stasis ulcers, and venous distention. Check

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the nail beds for capillary pulsation and color.

2. Palpation. Check for thrills and the vascular system for arteriosclerotic changes, shunts or AV anastomoses. The pulses should be examined to determine their character, to note if they are diminished or absent, and to observe for synchronicity.

3. Percussion. Determine heart size, diaphragmatic elevation/excursion, abnormal densities in the pulmonary fields, and mediastinal shift.

4. Auscultation. Check for resonance, asthmatic wheezing, ronchi, rales, cavernous breathing of emphysema, pulmonary or pericardial friction rubs, quality of the heart sounds, murmurs, heart rate, and rhythm. If a murmur exists, report its character, loudness, timing, transmission, and change with respiration. Auscult the neck for bruits.

It is recommended that the Examiner conduct the auscultation of the heart with the applicant both in a sitting and in a recumbent position.

Aside from murmur, irregular rhythm, and enlargement, the Examiner should be careful to observe for specific signs that are pathognomonic for specific disease entities or for serious generalized heart disease. Examples of such evidence are: (1 ) the opening snap at the apex or fourth left intercostal space signifying mitral stenosis; (2) gallop rhythm indicating serious impairment of cardiac function; and (3) the middiastolic rumble of mitral stenosis.

III. DISPOSITION

A. ITEM 35. Lungs and chest

1. The breast examination is performed only at the applicant’s option or if indicated by specific history or physical findings. If a breast examination is performed, the results are to be recorded in Item 60 of FAA Form 8500-8.

2. Asthma. (See D.1. below).

3. Bronchiectasis, if more than mild.

4. Emphysema, if of sufficient degree to be symptomatic.

5. Chronic obstructive pulmonary disease (COPD).

6. Fibrosis, if of sufficient degree to interfere with pulmonary function.

7. Fistula, bronchopleural, to include thoracostomy.

8. Infectious disease of the lungs, pleura, or mediastinum:

a. Abscesses.

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b. Mycotic disease which is active.

c. Tuberculosis which is active.

9. Lobectomy, until fully recovered, at which time the hospital records and results of pulmonary function tests will be obtained and forwarded to the Aeromedical Certification Division, AAM-300.

10. Pleura and pleural cavity:

a. Acute fibrinous pleurisy.

b. Pleurisy with effusion.

c. Empyema.

11. Pneumonectomy.

12. Spontaneous pneumothorax, until resolved as demonstrated by x-ray, and until it is determined that no condition that would be likely to cause recurrence is present.

13. Pneumothorax which is recurrent.

14. Sarcoid, if more than minimal involvement or if symptomatic.

15. Malignant tumors or cysts of the lung, pleura, mediastinum, or the breast.

16. Other diseases or defects of the lungs or chest wall that require use of medication or that could adversely affect flying or endanger the applicant’s well-being if permitted to fly.

B. ITEM 36. Heart

1. Myocardial infarction, angina pectoris, or other evidence of coronary heart disease. Reports and test results relating to the diagnosis in accordance with the attached protocol (see Appendix B) must be obtained and forwarded to the Aeromedical Certification Division, AAM-300.

2. Permanent cardiac pacemaker implantation.

3. Heart replacement.

4. Valve replacement.

5. Valvular disease of the heart and cardiac valve replacement will be evaluated in accordance with the procedures outlined in paragraph 12 below. Certification must be denied or deferred when any of the following diagnoses has been established:

a. Valvular stenosis.

b. Valvular regurgitation or insufficiency.

6. Arrhythmia will be evaluated in accordance with the procedure outlined in paragraph 12 below. Arrhythmias caused by organic heart disease and functional arrhythmias, other than sinus arrhythmia or occasional ventricular or atrial ectopic beats, are disqualifying.

7. Cardiac decompensation.

8. Congenital heart disease accompanied by cardiac enlargement, ECG abnormality, or evidence of inadequate oxygenation.

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9. Hypertrophy or dilatation of the heart as evidenced by clinical examination and supported by electrocardiographic and x-ray examination.

10. Murmur will be evaluated in accordance with the procedure outlined in paragraph 12 below.

11. Pericarditis, endocarditis, or myocarditis.

12. When cardiac arrhythmia, murmur or enlargement or other evidence of cardiovascular abnormality is found, issuance is deferred. If the applicant wishes further consideration, a consultation will be required “preferably” from a specialist in internal medicine or cardiology. (See FAA Form 8500-19, Appendix B). It must include a narrative report of evaluation and be accompanied by an electrocardiogram with report and appropriate laboratory test results which may include, as appropriate, 24-hour Holter monitoring, thyroid function studies, echocardiography, and an assessment of coronary artery status. The report and accompanying materials should be forwarded to the Aeromedical Certification Division, AAM-300. (See Item 58 for details regarding ECG’s).

C. ITEM 37. Vascular system

1. Aneurysm or arteriovenous fistula.

2. Blood and blood-forming tissue disease:

a. Anemia.

b. Hemophilia.

c. Leukemia.

d. Polycythemia.

e. Other disease of the blood or blood-forming tissues that could adversely affect performance of airman duties.

3. Peripheral edema. The Examiner should forward results of studies to determine the cause to the Aeromedical Certification Division, AAM-300.

4. Peripheral vascular disease:

a. Arteriosclerotic vascular disease with evidence of circulatory obstruction.

b. Buerger’s disease.

c. Intermittent claudication

d. Raynaud’s disease, or phenomenon.

e. Thrombophlebitis, or phlebothrombosis.

5. Syncope, not satisfactorily explained or recurrent.

Some respiratory, cardiac, and vascular conditions identified solely by history may be disqualifying. (See Item 18). Other conditions in these categories may produce clinical patterns that demand consideration of multiple etiologies. For example, syncope may involve cardiovascular, neurological, and psychiatric factors.

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(See Item 46 for detailed considerations of syncope).

The Examiner should keep in mind some of the special cardiopulmonary demands of flight. Heart rates at take-off and landing sometimes approach age-related maximums. High G-forces of aerobatics or agricultural flying may stress both systems considerably. Degenerative changes are often insidious and may produce subtle performance decrements that may require special investigative techniques.

D. Special Subjects

1. Asthma

Except for a history of mild or seasonal asthmatic symptoms, the Examiner should defer issuance and send the completed report to the Aeromedical Certification Division, AAM-300, for further evaluation and decision. If there is an established diagnosis of moderate or severe asthma, the FAA will usually ask for a report of evaluation by a medical specialist that includes the extent of the disease, medications required, and appropriate pulmonary function studies. Each case is evaluated on an individual basis and, if the FAA finds that an applicant is qualified, a certificate is issued. It may bear certain restrictions and special follow-up evaluations may be required.

When the applicant has asthma that requires use of medication, a report from the treating physician is necessary:

a. Type and dosage of medication.

b. Any side effect.

c. Duration of present therapy.

d. Nature and severity of any residual symptoms.

e. History of hospitalization or emergency room visits.

f. Likelihood of incapacitation.

2. Coronary Heart Disease

Some individuals with a history of myocardial infarction, angina pectoris, cardiac valve replacement, permanent cardiac pacemaker implantation, heart replacement, or coronary heart disease that has required treatment (including coronary artery bypass, coronary angioplasty, or other revascularization procedures; such as, stenting and endarterectomy) or, if untreated, that has been symptomatic or clinically significant, may be granted limited certificates through the special issuance section of Part 67 (14 CFR 67.401).

Title 14 CFR Part 67 specifies that an established medical history or clinical diagnoses of the above conditions are causes for denial no matter how remote or whether the applicant is currently symptomatic. It is only through consideration under the special issuance section of Part 67 (14 CFR 67.401) that the individual may be certified. An Examiner should not issue a certificate to an applicant

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with such a history unless specifically authorized to do so by the FAA. An applicant’s chances for a favorable decision through the special issuance section of Part 67 (14 CFR 67.401) depend upon many factors as evaluated by medical specialists who advise the FAA. Flight Standards specialists are consulted in situations in which functional limitations must be considered in the interest of aviation safety.

Applicants for first-, second-, or third-class certificates who have had myocardial infarctions, episodes of angina pectoris, cardiac valve replacement, permanent cardiac pacemaker implantation, or who have undergone coronary artery bypass surgery or angioplasty may be considered for Authorization for a Special Issuance of a Medical Certificate (Authorization) after 6 months have elapsed since the event or the surgery. This 6-month period is to allow for stabilization and recovery.

Applicants for any class of certificate who have a history of coronary heart disease must provide the FAA with complete pertinent hospital and other medical records, including admission and discharge summaries, daily progress notes, copies of all electrocardiograms, reports of other diagnostic and treatment procedures, laboratory reports, and outpatient progress notes. Records are required for nonsurgical admissions as well as for surgical admissions. (See Protocol for Evaluation of Coronary Heart Disease, Appendix B, page 27).

For all classes, certification decisions will be based on the applicant’s medical history and current clinical findings. First- or unlimited second-class certification is unlikely unless the information is highly favorable to the applicant. Evidence of extensive multi-vessel disease, impaired cardiac functioning, precarious coronary circulation, etc., will preclude certification. Before an applicant undergoes coronary angiography, it is recommended that all records and the report of a current cardiovascular evaluation, including a maximal electrocardiographic exercise stress test, be submitted to the FAA for preliminary review. Based upon this information, it may be possible to advise an applicant of the likelihood of favorable consideration.

3. Heart Murmur

When the Examiner discovers a heart murmur during the course of conducting a routine FAA examination, it should be noted whether it is functional or organic and if a special examination is needed. If the latter is indicated, the Examiner should defer issuance of the medical certificate and transmit the completed FAA Form 8500-8 to the FAA for further consideration.

4. Surgery

The presence of an aneurysm or obstruction of a major vessel of the body is disqualifying for medical certification of any class. Following successful surgical intervention and correction, the applicant may ask for FAA consideration. The FAA recommends that the applicant recover

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for at least 3-6 months. The likelihood of certification is enhanced in situations in which all medications have been discontinued and a current evaluation reveals n/o evidence of cardiovascular or renal disease.

A history of coronary artery bypass surgery is disqualifying for certification. Such surgery does not negate a past history of coronary heart disease. For details, see paragraph 2 of this section. The presence of permanent cardiac pacemakers and artificial heart valves is also disqualifying for certification. The FAA will consider an Authorization for a Special Issuance of a Medical Certificate (Authorization) for all the above conditions. Applicants seeking further FAA consideration should be prepared to submit all past records and a report of a complete current cardiovascular evaluation in accordance with FAA specifications.

5. Vascular Disease

Arteriosclerotic disease, when mild, may present no impediment to medical certification. At some point in the natural course of this disease process, the nature and severity of related symptoms or the potential for incapacitation may preclude continued certification. This is certainly true by the time surgical intervention is contemplated. Following surgery (such as an endarterectomy), the FAA will consider an Authorization under the special issuance section of Part 67 (14 CFR 67.401) unless significant uncorrected disease remains.

However, in addition to recovery from surgery and demonstration that the disease is not severe, these individuals must also show that there are no neurological deficits or signs of other cardiovascular disease, especially of the coronary arteries.

The applicant who has a history of pulmonary embolus without sequelae or need for medication may be certified. Often, such individuals are placed upon prophylactic or maintenance anticoagulant therapy such as warfarin. Use of any anticoagulant medication is disqualifying but can be considered for an Authorization under the special issuance section of Part 67 (14 CFR 67.401). When medical management results in a clinical status wherein medication is no longer a requirement, prospects for a favorable certification decision by the FAA are much improved.

ITEMS 38-39. Abdomen and Viscera and Anus

The digital rectal examination is performed only at the applicant’s option or if indicated by specific history or physical findings. If a digital examination is performed, the results are to be recorded in Item 59 of FAA Form 8500-8.

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I. CODE OF FEDERAL REGULATIONS

All Classes: 14 CFR 67.113(b)(c), 67.213(b)(c), and 67.313(b)(c)

***No other organic, functional, or structural disease, defect, or limitation that the Federal Air Surgeon, based on the case history and appropriate, qualified medical judgment relating to the medication or other treatment involved, finds-

Makes the person unable to safely perform the duties or exercise the privileges of the airman certificate applied for or held; or

May reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the person unable to perform those duties or exercise those privileges.

***No medication or other treatment that the Federal Air Surgeon, based on the case history and appropriate, qualified medical judgment relating to the medication or other treatment involved, finds—

Makes the person unable to safely perform the duties or exercise the privileges of the airman certificate applied for or held; or

May reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the person unable to perform those duties or exercise those privileges.

II. EXAMINATION PROCEDURES

A. Equipment

The only equipment needed for the conduct of the examination applicable to these items is that necessary for rectal examination — gloves or finger cots, lubricant, and wipes, if that examination should be required. However, medical history and/or physical findings may indicate a need for special tests (e.g., x-ray, laboratory studies).

B. Examination Techniques

In order to help reduce the likelihood of omissions and to conserve time, it is recommended that the Examiner follow a set protocol. The Examiner must review the applicant’s history prior to conducting the medical examination.

1. Observation — The Examiner should note any unusual shape or contour, skin color, moisture, temperature, and presence of scars. Hernias, hemorrhoids, and fissure should be noted and recorded.

2. Palpation — The Examiner should check for and note enlargement of organs, unexplained masses, tenderness, guarding, and rigidity.

3. Digital Rectal Examination — This examination is performed only at the applicant’s option unless indicated by specific history or physical findings.

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When performed, the following should be noted:

a. Sphincter tone.

b. Hemorrhoids.

c. Prostatic size and contour, consistency, tenderness.

d. Evidence of infection.

e. Unexplained masses.

f. Color of feces.

III. DISPOSITION

The following is a partial list of conditions that warrant denial or deferral to the Aeromedical Certification Division, AAM-300. All disqualifying defects are subject to further FAA consideration.

A. ITEM 38. Abdomen and viscera

1. Cholelithiasis.

2. Cirrhosis.

3. Hepatitis, acute; or chronic with impaired liver function.

4. Ventral or hiatal hernia, if symptomatic; or any hernia likely to incarcerate or strangulate.

5. Splenomegaly.

6. Malignancy.

7. Peptic ulcer. Following is special procedure for ulcer:

An applicant with a history of an active ulcer within the past 3 months or a bleeding ulcer within the past 6 months must provide evidence that the ulcer is healed if consideration for medical certification is desired. Evidence of healing must be verified by a report from the attending physician that includes the following information:

·  Confirmation that the applicant is free of symptoms

·  Radiographic or endoscopic evidence that the ulcer has healed.

·  Type, dosage, and frequency of medication used.

This information should be submitted to the Aeromedical Certification Division, AAM-300. Under favorable circumstances, the FAA may issue a certificate with special requirements. For example, an applicant with a history of bleeding ulcer may be required to have the physician submit follow-up reports every 6 months for 1 year following initial certification. The prophylactic use of medications including simple antacids, H-2 inhibitors or blockers, and/or sucralfates may not be disqualifying. An applicant with a history of gastric resection for ulcer may be favorably considered if free of sequelae.

8. Regional enteritis. The episodic occurrence of symptoms and the need for medications and the type of medications used for treatment of regional enteritis are of concern to the

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FAA. Six months after surgery; however, the applicant’s eligibility for medical certification could be established upon written evidence from the surgeon that recovery is complete.

An applicant after a colectomy with an ileostomy or a colostomy may also receive FAA consideration. A report is necessary to confirm that the applicant has fully recovered from the surgery and is completely asymptomatic.

B. ITEM 39. Anus

If the rectal examination is not performed, the response to Item 39 may be based on direct observation or history.

ITEM 40. Skin

I. CODE OF FEDERAL REGULATIONS

All Classes: 14 CFR 67.113(b)(c), 67.213(b)(c), and 67.313(b)(c)

Makes the person unable to safely perform the duties or exercise the privileges of the airman certificate applied for or held; or

May reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the person unable to perform those duties or exercise those privileges.

II. EXAMINATION PROCEDURES

A. Equipment

None required.

B. Examination Techniques

A careful examination of the skin may reveal underlying systemic disorders of clinical importance. For example, thyroid disease may produce changes in the skin and fingernails. Cushing’s disease may produce abdominal

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striae, and abnormal pigmentation of the skin occurs with Addison’s disease.

Needle marks that suggest drug abuse should be noted and body marks and scars should be described and correlated with known history. Further history should be obtained as needed to explain findings.

III. DISPOSITION

The following is a partial list of conditions that warrant denial or deferral to the Aeromedical Certification Division, AAM-300. All disqualifying defects are subject to further FAA consideration.

ITEM 40. Skin

1. Malignant melanoma with or without evidence of metastasis.

2. Scar tissue that involves loss of function sufficient to interfere with the safe performance of airman duties.

3. Neurofibromatosis with central nervous system involvement.

4. Cutaneous evidence of the following systemic diseases:

a. Lupus erythematosus.

b. Dermatomyositis.

c. Scleroderma.

d. Raynaud’s phenomenon.

e. Sarcoid.

f. Eruptive xanthomas.

g. Hansen’s disease.

h. Deep mycotic infections.

i. Kaposi’s sarcoma.

ITEM 41. G-U system

The pelvic examination is performed only at the applicant’s option or if indicated by specific history or physical findings. If a pelvic examination is performed, the results are to be recorded in Item 60 of FAA Form 8500-8.

I. CODE OF FEDERAL REGULATIONS

All Classes: 14 CFR 67.113(b)(c), 67.213(b)(c), and 67.313(b)(c)

Makes the person unable to safely perform the duties or exercise the privileges of the airman certificate applied for or held; or

May reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the person unable to perform those

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duties or exercise those privileges.

Makes the person unable to safely perform the duties or exercise the privileges of the airman certificate applied for or held; or

May reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the person unable to perform those duties or exercise those privileges.

II. EXAMINATION PROCEDURES

A. Equipment

No special equipment is needed for routine examination

B. Examination Techniques

The Examiner should observe for discharge, inflammation, skin lesions, scars, strictures, tumors, and secondary sexual characteristics. Palpation for masses and areas of tenderness should be performed. The pelvic examination is performed only at the applicant’s option or if indicated by specific history or physical findings. If a pelvic examination is performed, the results are to be recorded in Item 60 of FAA Form 8500-8. Disorders such as sterility and menstrual irregularity are not usually of importance in qualification for medical certification. Specialty evaluations may be indicated by history or by physical findings on the routine examination. A personal history of urinary symptoms is important; such as:

1. Pain or burning upon urination.

2. Dribbling or incontinence.

3. Polyuria, frequency, or nocturia.

4. Hematuria, pyuria, or glycosuria.

Special procedures for evaluation of the G-U system should best be left to the discretion of a urologist, nephrologist, or gynecologist.

III. DISPOSITION

The following is a partial list of conditions that warrant denial or deferral to the Aeromedical Certification Division, AAM-300. All disqualifying defects are subject to further FAA consideration.

(See Item 48 for details concerning diabetes and Item 57 for other information related to the examination of urine).

A. Urinary System

1. Calculus: renal, ureteral, or vesical (see 11 below).

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2. Hydronephrosis with impaired renal function.

3. Nephrectomy, if associated with hypertension, uremia, infection of the remaining kidney, or other evidence of reduced renal function in the remaining kidney.

4. Nephritis: acute or chronic.

5. Nephrocalcinosis.

6. Nephrosis.

7. Polycystic kidney disease.

8. Pyelitis or pyelonephritis.

9. Pyonephrosis.

10. Tumors or malignancies, including prostatic carcinoma, require further evaluation.

11. Retained stones are disqualifying for issuance of a medical certificate. The Examiner should either deny or defer issuance and transmit the completed FAA Form 8500-8 to the Aeromedical Certification Division. Complete studies to determine the possible etiology and prognosis are essential to favorable FAA consideration. Determining factors include site and location of the stones, complications such as compromise in renal function, repeated bouts of kidney infection, and need for therapy. Any underlying disease will be considered. The likelihood of sudden incapacitating symptoms is of primary concern. (See Item 18.j.).

12. Congenital lesions of the kidney are often benign, and certification of applicants with ectopic and horseshoe kidney, agenesis (unilateral), and even hypoplasia and dysplasia is possible.

13. Cystostomy and neurogenic bladder require evaluation by a specialist and deferral of certification to the Aeromedical Certification Division, AAM-300.

14. Glycosuria requires special evaluation. (Also see Items 48 and 57 for glycosuria associated with diabetes).

15. Renal dialysis and transplant are cause for denial. FAA certification may be possible after complete recovery from surgery and in limited circumstances involving dialysis.

B. Genital/Reproductive System

1. Use of oral or repository contraceptives or hormonal replacement therapy are not disqualifying for medical certification. If the applicant is experiencing no adverse symptoms or reactions to cyclic hormones and is otherwise qualified, the Examiner may issue the desired certificate.

2. Pregnancy under normal circumstances is not disqualifying. It is recommended that the applicant’s obstetrician be made aware of all aviation activities so that the obstetrician can properly advise the applicant. The Examiner may wish to counsel applicants concerning piloting aircraft during the third trimester, and

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the proper use of lap belt and shoulder harness warrants discussion.

ITEMS 42-43. Musculoskeletal

I. CODE OF FEDERAL REGULATIONS
All Classes: 14 CFR 67.113(b)(c), 67.213(b)(c), and 67.313(b)(c)

***No other organic, functional, or structural disease, defect, or limitation that the Federal Air Surgeon, based on the case history and appropriate, qualified medical judgment relating to the condition involved finds—

Makes the person unable to safely perform the duties or exercise the privileges of the airman certificate applied for or held; or

May reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the person unable to perform those duties or exercise those privileges.

***No medication or other treatment that the Federal Air Surgeon, based on the case history and appropriate, qualified medical judgment relating to the medication or other treatment involved, finds—

Makes the person unable to safely perform the duties or exercise the privileges of the airman certificate applied for or held; or

May reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the person unable to perform those duties or exercise those privileges.

II. EXAMINATION PROCEDURES

A. Equipment

No special equipment is required.

B. Examination Techniques

Standard examination procedures should be used to make a gross evaluation of the integrity of the applicant’s musculoskeletal system. The Examiner should note —

1. Pain — neuralgia, myalgia, paresthesia, and related circulatory and neurological findings.

2. Weakness — local or generalized; degree and amount of functional loss.

3. Paralysis — atrophy, contractures, and related dysfunctions.

4. Motion coordination, tremors, loss or restriction of joint motions, and performance degradation.

5. Deformity — extent and cause.

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6. Amputation — level, stump healing, and phantom pain.

7. Prostheses — comfort and ability to use effectively.

(See Item 46 for the neurological evaluation of motor functions).

III. DISPOSITION

The following is a partial list of conditions that warrant denial or deferral to the Aeromedical Certification Division, AAM-300. All disqualifying defects are subject to further FAA consideration.

A. ITEM 42. Upper and lower extremities

1. Atrophy of any muscles that is progressive or is sufficient to interfere with the performance of airman duties.

2. Deformities, either congenital or acquired, if sufficient to interfere with the performance of airman duties.

3. Limitation of motion of a major joint, if sufficient to interfere with the performance of airman duties.

4. Neuralgia or neuropathy, chronic or acute, particularly sciatica, if sufficient to interfere with function or is likely to become incapacitating.

5. Osteomyelitis, acute or chronic, with or without draining fistula(e).

6. Tremors, if sufficient to interfere with the performance of airman duties.

7. Amputations. After review of all medical data, the FAA may authorize a special medical flight test.

The Examiner should defer issuance. If the applicant is otherwise qualified, the FAA may issue a limited certificate. This certificate will permit the applicant to proceed with flight training until ready for a medical flight test. At that time, at the applicant’s request, the FAA (usually the Aeromedical Certification Division, AAM-300) will authorize the student pilot to take a medical flight test in conjunction with the regular flight test. The medical flight test and regular private pilot flight test are conducted by an FAA inspector. This affords the student an opportunity to demonstrate the ability to control the aircraft despite the handicap. The FAA inspector prepares a written report and indicates whether there is a safety problem. A medical certificate and SODA, without the student limitation, may be provided to the inspector for issuance to the applicant, or the inspector may be required to send the report to the FAA medical officer who authorized the test.

When prostheses are used or additional control devices are installed in an aircraft to assist the amputee, those found qualified by special certification procedures will have their certificates limited to require that the devices (and, if necessary, even the specific aircraft) must always be used when exercising the privileges of the airman certificate.

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B. ITEM 43. Spine, other musculoskeletal

1. Active disease of bones and joints.

2. Curvature, ankylosis, or other marked deformity of the spinal column sufficient to interfere with the performance of airman duties.

3. Symptomatic herniation of intervertebral disc.

4. Other disturbances of musculoskeletal function, congenital or acquired, sufficient to interfere with the performance of airman duties or likely to progress to that degree, such as:

a. Musculoskeletal effects of cerebral palsy.

b. Myasthenia gravis.

c. Muscular dystrophy or other myopathies.

5. Arthritis, if it is symptomatic or requires medication (other than small doses of nonprescription anti-inflammatory agents), is disqualifying unless the applicant holds a letter from the FAA specifically authorizing the Examiner to issue the certificate when the applicant is found otherwise qualified. Although the use of many medications on a continuing basis ordinarily contraindicates the performance of pilot duties, under certain circumstances, certification is possible for an applicant who is taking aspirin, ibuprofen, naproxen, or similar nonsteroidal anti-inflammatory drugs (NSAID). If the applicant presents evidence documenting that the underlying condition for which the medicine is being taken is not in itself disabling and the applicant has been on therapy (NSAID) long enough to have established that the medication is well tolerated and has not produced adverse side effects, the Examiner may issue a certificate.

6. A history of intervertebral disc surgery is not disqualifying. If the applicant is asymptomatic, has completely recovered from surgery, is taking no medication, and has suffered no neurological deficit, the Examiner should confirm these facts in a brief statement in Item 60. The Examiner may then issue any class of medical certificate, providing that the individual meets all the medical standards for that class.

7. The paraplegic whose paralysis is not the result of a progressive disease process is considered in much the same manner as an amputee. The Examiner should defer issuance and may advise the applicant to request further FAA consideration. The applicant may be authorized to take a medical flight test along with the private pilot certificate flight test. If successful, the limitation VALID FOR STUDENT PILOT PURPOSES ONLY is removed from the medical certificate, but operational limitations may be added. A SODA is issued.

8. Other neuromuscular conditions are covered in more detail in Item 46.

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ITEM 44. Identifying body marks, scars, tattoos

I. CODE OF FEDERAL REGULATIONS

All Classes: 14 CFR 67.113(b),
67.213(b), and 67.313(b)

I. CODE OF FEDERAL REGULATIONS

All Classes: 14 CFR 67.113(b),
67.213(b), and 67.313(b)

Makes the person unable to safely perform the duties or exercise the privileges of the airman certificate applied for or held; or

May reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the person unable to perform those duties or exercise those privileges.

B. Examination Techniques

A careful examination for surgical and other scars should be made, and those that are significant (the result of surgery or that could be useful as identifying marks) should be described. Tattoos should be recorded because they may be useful for identification.

III. DISPOSITION

The following condition warrants denial or deferral to the Aeromedical Certification Division, AAM-300. All disqualifying defects are subject to further FAA consideration.

Scar tissue that involves the loss of function which may interfere with the safe performance of airman duties.

ITEM 45. Lymphatics

I. CODE OF FEDERAL REGULATIONS

All Classes: 14 CFR 67.113(b)(c), 67.213(b)(c), and 67.313(b)(c)

Makes the person unable to safely perform the duties or exercise the privileges of the airman certificate applied for or held; or

May reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the person unable to perform those duties or exercise those privileges.

II. EXAMINATION PROCEDURES

A. Equipment

None required.

B. Examination Techniques

A careful examination of the Iymphatic system may reveal underlying systemic disorders of clinical importance. Further history should be obtained as needed to explain findings.

III. DISPOSITION

The following is a partial list of conditions that warrant denial or deferral to the Aeromedical Certification Division, AAM-300. All disqualifying defects are subject to further FAA consideration.

ITEM 45. Lymphatics

1. Adenopathy secondary to systemic disease or metastasis.

2. Hodgkin’s disease, Iymphoma, lymphosarcoma.

3. Lymphedema.

ITEM 46. Neurologic

I. CODE OF FEDERAL REGULATIONS

All Classes: 14 CFR 67.109(a)(b), 67.209(a)(b), and 67.309(a)(b)

***No established medical history or clinical diagnosis of any of the following:

Epilepsy.

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A disturbance of consciousness without satisfactory medical explanation of the cause; or

A transient loss of control of nervous system function(s) without satisfactory medical explanation of the cause;

***No other seizure disorder, disturbance of consciousness, or neurologic condition that the Federal Air Surgeon, based on the case history and appropriate, qualified medical judgment relating to the condition involved, finds—

Makes the person unable to safely perform the duties or exercise the privileges of the airman certificate applied for or held; or

May reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the person unable to perform those duties or exercise those privilege

II. EXAMINATION PROCEDURES

A. History

A neurologic evaluation should consist of a thorough review of the applicant’s history prior to the neurological examination. In addition to items of the medical history contained in Item 18, the Examiner should specifically inquire concerning a history of weakness or paralysis, disturbance of sensation, loss of coordination, or loss of bowel or bladder control. Certain laboratory studies, such as scans and imaging procedures of the head or spine, electroencephalograms, or spinal paracentesis may suggest significant medical history. The Examiner should note conditions identified in Item 60 with facts, such as dates, frequency, and severity of occurrence.

B. Examination Techniques

The basic neurological examination consists of an examination of the 12 cranial nerves, motor strength, superficial reflexes, deep tendon reflexes, sensation, coordination, mental status, and includes the Babinski reflex and Romberg sign. The Examiner should be aware of any asymmetry in responses because this may be evidence of mild or early abnormalities. The Examiner should evaluate the visual field by direct confrontation or, preferably, by one of the perimetry procedures (see Item 53), especially if there is a suggestion of neurological deficiency.

III. DISPOSITION

The following is a partial list of conditions that warrant denial or deferral to the Aeromedical Certification Division, AAM-300. All disqualifying defects are subject to further FAA consideration.

A. An established history of any of the following conditions is disqualifying for medical certification:

1. Epilepsy.

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2. Transient loss of nervous system function(s) without satisfactory medical explanation of the cause; e.g., transient global amnesia.

3. A disturbance of consciousness without satisfactory medical explanation of the cause; e.g., unexplained syncope, single seizure. An applicant who has a history of epilepsy, a disturbance of consciousness without satisfactory medical explanation of the cause, or a transient loss of control of nervous system function(s) without satisfactory medical explanation of the cause must be denied or deferred by the Examiner. Infrequently, the FAA has granted an Authorization under the special issuance section of Part 67 (14 CFR 67.401) when a seizure disorder was present in childhood but the individual has been seizure-free for a number of years. Factors that would be considered in determining eligibility in such cases would be age at onset, nature and frequency of seizures, precipitating causes, and duration of stability without medication. Follow-up evaluations are usually necessary to confirm continued stability of an individual’s condition if an Authorization is granted under the special issuance section of Part 67 (14 CFR 67.401).

Applicants who have a history of an unexplained disturbance of consciousness may also be granted an Authorization under the special issuance section of Part 67 (14 CFR 67.401), but usually only after a prolonged period without recurrent episodes.

B. A history or the presence of any neurological condition or disease that potentially may incapacitate an individual should be regarded as initially disqualifying. Issuance of a medical certificate to an applicant in such cases should be denied or deferred pending further evaluation. A convalescence period following illness or injury may be advisable to permit adequate stabilization of an individual’s condition and to reduce the risk of an adverse event. Applications from individuals with potentially disqualifying conditions should be forwarded to the FAA. Processing such applications can be expedited by including hospital records, consultation reports, and appropriate laboratory and imaging studies, if available. Symptoms or disturbances that are secondary to the underlying condition and that may be acutely incapacitating include pain, weakness, vertigo or incoordination, seizures or a disturbance of consciousness, visual disturbance, or mental confusion. Chronic conditions may be incompatible with safety in aircraft operation because of long-term unpredictability, severe neurologic deficit, or psychological impairment.

A history or the presence of any of the following conditions precludes issuance of a medical certificate:

1. Head trauma associated with:

a. Unconsciousness or disorientation of more than 1 hour following injury.

b. Focal neurologic deficit.

c. Depressed skull fracture.

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d. Post-traumatic headache.

e. Subdural or epidural hematoma.

Complete neurological evaluation with appropriate laboratory and imaging studies will be required to determine an applicant’s eligibility. A period of stabilization will usually be required to confirm that an applicant has adequately recovered from any of the above conditions before he or she is considered for medical certification.

2. Headache.

a. Migraine.

b. Migraine equivalent.

c. Cluster headache.

d. Chronic tension headache.

e. Conversion headache.

3. Other Conditions.

a. Trigeminal neuralgia.

b. Atypical facial pain.

Pain, in some conditions, may be acutely incapacitating. Chronic recurring headaches or pain syndromes often require medications for relief or prophylaxis, and, in most instances, the use of such medications is disqualifying because they may interfere with a pilot’s alertness and functioning. The Examiner may issue a medical certificate to an applicant with a long standing history of headaches if mild, seldom requiring more than simple analgesics, occur infrequently, and are not incapacitating, and are not associated with neurological stigmata.

4. Vertigo or disequilibrium.

a. Meniere’s disease and acute peripheral vestibulopathy.

b. Alternobaric vertigo.

c. Hyperventilation syndrome.

d. Orthostatic hypotension.

e. Nonfunctioning labyrinths.

Numerous conditions may affect equilibrium, resulting in acute incapacitation or varying degrees of chronic recurring spatial disorientation. Prophylactic use of medications also may affect pilot performance. In most instances, further neurological evaluation will be required to determine eligibility for medical certification; therefore, issuance of a medical certificate should be deferred.

5. Cerebrovascular disease (including the brain stem).

a. Transient ischemic attack (TIA).

b. Brain infarction.

c. Intracerebral or subarachnoid hemorrhage.

d. Intracranial aneurysm or arteriovenous malformation.

Complete neurological evaluations supplemented with appropriate laboratory and imaging studies are

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required of applicants with the above conditions. Cerebral arteriography may be necessary for review in cases of subarachnoid hemorrhage.

6. Intracranial tumor.

a. A variety of intracranial tumors, both malignant and benign, are capable of causing incapacitation directly by neurologic deficit or indirectly through recurrent symptomatology. Potential neurologic deficits include weakness, loss of sensation, ataxia, visual deficit, or mental impairment. Recurrent symptomatology may interfere with flight performance through mechanisms such as seizure, headaches, vertigo, visual disturbances, or confusion. A history or diagnosis of an intracranial tumor necessitates a complete neurological evaluation with appropriate laboratory and imaging studies before a determination of eligibility for medical certification can be established. An applicant with a history of benign supratentorial tumors may be considered favorably for medical certification by the FAA and returned to flying status after a minimum satisfactory convalescence of 1 year.

b. Pseudotumor cerebri (benign intracranial hypertension). Although the ultimate prognosis of this condition usually is good, the Examiner should defer issuance of a medical certificate and forward medical records to the Aeromedical Certification Division, AAM-300.

7. Hydrocephalus and shunts.

a. Hydrocephalus secondary to a known injury or disease process.

b. Normal pressure hydrocephalus.

Individuals with a history or diagnosis of hydrocephalus or a corrective shunt should be deferred issuance of a medical certificate. Eligibility for Authorization under the special issuance section of Part 67 (14 CFR 67.401) will be determined by the FAA.

8. Spasticity, weakness, or paralysis of the extremities. Conditions that are stable and nonprogressive may be considered for medical certification. In addition to hospital records, the information necessary for determining eligibility for medical certification includes the medical history, etiology of the neurological condition, degree of involvement, period of stability, and total current health and neurological status of the individual. Neurological consultation, including appropriate laboratory and imaging studies, will be required. The Examiner should defer issuance of a medical certificate and forward records to the Aeromedical Certification Division, AAM-300.

9. Demyelinating and autoimmune disease.

a. Multiple sclerosis.

b. Acute optic neuritis.

c. Myasthenia gravis.

d. Landry-Guillain-Barre syndrome.

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e. Allergic encephalomyelitis.

f. Collagen disease.

(1) Lupus erythematosus.

(2) Periarteritis nodosa.

(3) Acute polymyositis.

(4) Dermatomyositis.

Because of the variability and unpredictability of involvement and course of the above conditions, the FAA must consider each applicant’s case to determine eligibility for medical certification. Factors used in determining eligibility will include the medical history, neurological involvement and persisting deficit, period of stability without symptoms, type and dosage of medications used, and general health. A neurological and/or general medical consultation will be necessary in most instances. The Examiner should defer issuance of a medical certificate and forward medical records to the Aeromedical Certification Division, AAM-300.

10. Extrapyramidal, hereditary, and degenerative diseases of the nervous system.

a. Parkinson’s disease.

b. Huntington’s disease.

c. Wilson’s disease.

d. Dystonia musculorum deformans.

e. Gilles de la Tourette syndrome.

f. Creutzfeldt-Jakob’s disease and other similar slow viral diseases.

g. Alzheimer’s disease.

h. Dementia (unspecified).

Considerable variability exists in the severity of involvement, rate of progression, and treatment of the above conditions. A complete neurological evaluation with appropriate laboratory and imaging studies, including information specifically on the above factors, will be necessary for determination of eligibility for medical certification.

Conditions that have a poor prognosis will likely be denied. The applicant should not be encouraged to pursue medical certification.

11. Infections of the nervous system.

a. Meningitis.

b. Brain abscess.

c. Encephalitis.

d. Neurosyphilis.

e. AIDS.

Many different types of infection of the nervous system exist, and postinfectious complications and degree of recovery may differ widely. The most significant factors to be considered include the possibility of a seizure disorder or mental impairment. A complete neurological evaluation with appropriate laboratory and imaging studies will be required to

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determine eligibility for medical certification. The Examiner should defer issuance of a medical certificate and forward medical records to the Aeromedical Certification Division, AAM-300.

12. Other neurological conditions.

Many other neurological conditions may be disqualifying for airman medical certification. The above-listed conditions represent only some of the major disqualifying problems.

NOTE: Essential tremor is not disqualifying unless it is disabling.

ITEM 47. Psychiatric

I. CODE OF FEDERAL REGULATIONS

All Classes: 14 CFR 67.107, 67.207, and 67.307

***No established medical history or clinical diagnosis of any of the following:

A personality disorder that is severe enough to have repeatedly manifested itself by overt acts.

A psychosis. As used in this section, “psychosis” refers to a mental disorder in which:

The individual has manifested delusions, hallucinations, grossly bizarre or disorganized behavior, or other commonly accepted symptoms of this condition; or

The individual may reasonably be expected to manifest delusions, hallucinations, grossly bizarre or disorganized behavior, or other commonly accepted symptoms of this condition.

A bipolar disorder.

Substance dependence, except where there is established clinical evidence, satisfactory to the Federal Air Surgeon, of recovery, including sustained total abstinence from the substance(s) for not less than the preceding 2 years. As used in this section—

“Substance” includes: Alcohol; other sedatives and hypnotics; anxiolytics; opioids; central nervous system stimulants such as cocaine, amphetamines, and similarly acting sympathomimetics; hallucinogens; phencyclidine or similarly acting arylcyclohexylamines; cannabis; inhalants; and other psychoactive drugs and chemicals; and

“Substance dependence” means a condition in which a

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person is dependent on a substance, other than tobacco or ordinary xanthine-containing (e.g., caffeine) beverages, as evidenced by—

Increased tolerance

Manifestation of withdrawal symptoms;

Impaired control of use; or

Continued use despite damage to physical health or impairment of social, personal, or occupational functioning.

***No substance abuse within the preceding 2 years defined as:

Use of a substance in a situation in which that use was physically hazardous, if there has been at any other time an instance of the use of a substance also in a situation in which that use was physically hazardous;

A verified positive drug test result acquired under an anti-drug program or internal program of the U.S. Department of Transportation or any other Administration within the U.S. Department of Transportation; or

Misuse of a substance that the Federal Air Surgeon, based on case history and appropriate, qualified medical judgment relating to the substance involved, finds—

Makes the person unable to safely perform the duties or exercise the privileges of the airman certificate applied for or held; or

May reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the person unable to perform those duties or exercise those privileges.

***No other personality disorder, neurosis, or other mental condition that the Federal Air Surgeon, based on the case history and appropriate, qualified medical judgment relating to the condition involved, finds—

Makes the person unable to safely perform the duties or exercise the privileges of the airman certificate applied for or held; or

May reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the person unable to perform those duties or exercise those privileges.

(Also see Items 18.m., n., p.).

II. EXAMINATION PROCEDURES

A. Equipment

No psychological tests or other special software or hardware are routinely

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required for the Examiner’s evaluation of mental problems.

B. Examination Techniques

The FAA does not expect the Examiner to perform a psychiatric examination. However, the Examiner should form a general impression of the emotional stability and mental state of the applicant. There is a need for discretion in the Examiner/applicant relationship consonant with the FAA’s aviation safety mission and the concerns of all applicants regarding disclosure to a public agency of sensitive information that may not be pertinent to aviation safety. Examiners must be sensitive to this need while, at the same time, collect what is necessary for a certification decision. When a question arises, the Federal Air Surgeon encourages Examiners first to check this Guide for Aviation Medical Examinersand other FAA informational documents. If the question remains unresolved, the Examiner should seek advice from a Regional Flight Surgeon or the Manager of the Aeromedical Certification Division.

Review of the applicant’s history as provided on the application form may alert the Examiner to gather further important factual information. Information about the applicant may be found in items related to age, pilot time, and class of certificate for which applied. Information about the present occupation and employer also may be helpful. If any psychotropic drugs are or have been used, follow-up questions are appropriate. Previous medical denials or aircraft accidents may be related to psychiatric problems.

Psychiatric information can be derived from the individual items in medical history (Item 18). Any affirmative answers to Item 18.m., ” Mental disorders of any sort; depression, anxiety, etc.,” or Item 18.p., “Suicide attempt,” are significant. Any disclosure of current or previous alcohol or drug problems requires further clarification. A record of traffic violations may reflect certain personality problems or indicate an alcohol problem. Affirmative answers related to rejection by military service or a military medical discharge require elaboration. Reporting symptoms such as headaches or dizziness, or even heart or stomach trouble, may reflect a history of anxiety rather than a primary medical problem in these areas. Sometimes, the information applicants give about their previous diagnoses is incorrect, either because the applicant is unsure of the correct information or because the applicant chooses to minimize past difficulties. If there was a hospital admission for any emotionally related problem, it will be necessary to obtain the entire record.

Valuable information can be derived from the casual conversation that occurs during the physical examination. Some of this conversation will reveal information about the family, the job, and special interests. Even some personal troubles may be revealed at this time. The Examiner’s questions should not be stilted or follow a regular pattern; instead, they should be a natural extension of the Examiner’s curiosity about the person being examined.

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Information about the motivation for medical certification and interest in flying may be revealing. A formal Mental Status Examination is unnecessary. For example, it is not necessary to ask about time, place, or person to discover whether the applicant is oriented. Information about the flow of associations, mood, and memory, is generally available from the usual interactions during the examination. Indication of cognitive problems may become apparent during the examination. Such problems with concentration, attention, or confusion during the examination or slower, vague responses should be noted and may be cause for deferral.

The Examiner should make observations about the following specific elements and should note on the form any gross or notable deviations from normal:

1. Appearance (abnormal if dirty, disheveled, odoriferous, or unkempt).

2. Behavior (abnormal if uncooperative, bizarre, or inexplicable).

3. Mood (abnormal if excessively angry, sad, euphoric, or labile).

4. Communication (abnormal if incomprehensible, does not answer questions directly).

5. Memory (abnormal if unable to recall recent events).

6. Cognition (abnormal if unable to engage in abstract thought, or if delusional or hallucinating).

Significant observations during this part of the medical examination should be recorded in Item 60 of the application form. The Examiner, upon identifying any significant problems, should defer issuance of the medical certificate and report findings to the FAA. This could be accomplished by contacting a Regional Flight Surgeon or the Manager of the Aeromedical Certification Division.

III. DISPOSITION

A. General Considerations

It must be pointed out that considerations for safety, which in the “mental” area are related to a compromise of judgment and emotional control or to diminished mental capacity with loss of behavioral control, are not the same as concerns for emotional health in everyday life. Some problems may have only a slight impact on an individual’s overall capacities and the quality of life but may nevertheless have a great impact on safety. Conversely, many emotional problems that are of therapeutic and clinical concern have no impact on safety.

The reasons that an applicant has seen a mental health professional needs to be revealed, but may be found not to have significance for medical certification. For instance, growth and adjustment problems requiring psychotherapy are usually not considered significant for safety when there have been no vocational disruptions and medications have not been used. This might include marital counseling or psychotherapy for

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identity problems or issues of growth and personal fulfillment. A history of brief situational problems secondary to such life events as marital disruption, business problems, and the death of loved ones may likewise not be significant. Also, sexual behavior that does not reflect upon overall judgment and self-control is not a concern for safety.

B. Denials

The FAA has concluded that certain psychiatric conditions are such that their presence or a past history of their presence is sufficient to suggest a significant potential threat to safety. It is, therefore, incumbent upon the Examiner to be aware of any indications of these conditions currently, or in the past, and to deny or defer issuance of the medical certificate to an applicant who has a history of these conditions. An applicant who has a current diagnosis or history of these conditions (listed below) may request the FAA to grant an Authorization under the special issuance section of Part 67 (14 CFR 67.401) and, based upon individual considerations, the FAA may grant such an issuance.

The use of a psychotropic drug is considered disqualifying. This includes all sedatives, tranquilizers, antipsychotic drugs, antidepressant drugs (including SSRI’s), analeptics, anxiolytics, and hallucinogens. The Examiner should defer issuance and forward the medical records to the Aeromedical Certification Division, AAM-300.

1. The category of personality disorder severe enough to have repeatedly manifested itself by overt acts refers to diagnosed personality disorders that involve what is called “acting out” behavior. These personality problems relate to poor social judgment, impulsivity, and disregard or antagonism toward authority, especially rules and regulations. A history of long-standing behavioral problems, whether major (criminal) or relatively minor (truancy, military misbehavior, petty criminal and civil indiscretions, and social instability), usually occurs with these disorders. Driving infractions and previous failures to follow aviation regulations are critical examples of these acts.

2. The category of psychosis includes schizophenia and some bipolar and major depression, as well as some other rarer conditions. In addition, some conditions such as schizotypal and borderline personality disorders that include psychotic symptoms at some time in their course may also be disqualifying.

3. A bipolar disorder may not reach the level of psychosis but can be so disruptive of judgment and functioning (especially mania) so as to interfere with aviation safety. All applicants with such a diagnosis must be denied or deferred. However, a number of these applicants, so diagnosed, may be favorably considered for an Authorization when the symptoms do not constitute a threat to safe aviation operations.

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4. Certain personality disorders and other mental disorders that include conditions of limited duration and/or widely varying severity may be disqualifying. Under this category, the FAA is especially concerned with significant depressive episodes requiring treatment, even outpatient therapy. If these episodes have been severe enough to cause some disruption of vocational or educational activity, or if they have required medication or involved suicidal ideation, the application should be deferred or denied issuance.

Some personality disorders and situational dysphorias may be considered disqualifying for a limited time. These include such conditions as gross immaturity and some personality disorders not involving or manifested by overt acts.

Although they may be rare in occurrence, severe anxiety problems, especially anxiety and phobias associated with some aspect of flying, are considered significant. Organic mental disorders that cause a cognitive defect, even if the applicant is not psychotic, are considered disqualifying whether they are due to trauma, toxic exposure, or arteriosclerotic or other degenerative changes.

(See Item 18.m. for Nos. 1-4).

5. Substance dependence refers to the use of substances of dependence, which include alcohol and other drugs (i.e., PCP, sedatives and hynoptics, anxiolytics, marijuana, cocaine, opioids, amphetamines, hallucinogens, and other psychoactive drugs or chemicals). Substance dependence is defined and specified as a disqualifying medical condition. It is disqualifying unless there is clinical evidence, satisfactory to the Federal Air Surgeon, of recovery, including sustained total abstinence from the substance for not less than the preceding 2 years.

Substance dependence is evidenced by one or more of the following: Increased tolerance, manifestation of withdrawal symptoms, impaired control of use, or continued use despite damage to physical health or impairment of social, personal, or occupational functioning. Substance dependence is accompanied by various deleterious effects on physical health as well as personal or social functioning. There are many other indicators of substance dependence in the history and physical examination. Treatment for substance dependence-related problems, arrests, including charges of driving under the influence of drugs or alcohol, and vocational or marital disruption related to drugs or alcohol consumption are important indicators. Alcohol on the breath at the time of a routine physical examination should arouse a high index of suspicion. Consumption of drugs or alcohol sufficient to cause liver damage is an indication of the presence of alcoholism.

6. Substance abuse includes the use of the above substances under any one of the following conditions:

a. Use of a substance in the last 2 years in which the use was physically hazardous (e.g., DUI or DWI) if there has been at any other

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time an instance of the use of a substance also in a situation in which the use was physically hazardous;

b. If a person has received a verified positive drug test result under an anti-drug program of the Department of Transportation or one of its administrations; or

c. The Federal Air Surgeon finds that an applicant’s misuse of a substance makes him or her unable to safely perform the duties or exercise the privileges of the airman certificate applied for or held, or that may reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the applicant unable to perform those duties or exercise those privileges.

Substance dependence and substance abuse are specified as disqualifying medical conditions.

ITEM 48. General systemic

I. CODE OF FEDERAL REGULATIONS

All Classes: 14 CFR 67.113(a)(b)(c), 67.213(a)(b)(c), and 67.313(a)(b)(c)

***No established medical history or clinical diagnosis of diabetes mellitus that requires insulin or any other hypoglycemic drug for control.

Makes the person unable to safely perform the duties or exercise the privileges of the airman certificate applied for or held; or

May reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the person unable to perform those duties or exercise those privileges.

II. EXAMINATION PROCEDURES

A. Equipment

No special equipment is required.

B. Examination Techniques

A protocol for examinations applicable to Item 48 is not provided because the necessary history taking, observation, and other examination techniques used in examining other systems have already revealed much of what can be known about the status of the applicant’s endocrine and other systems. For example, the examination of the skin alone can reveal important signs of thyroid dysfunction, Addison’s disease, Cushing’s disease, and several other endocrine disorders. The eye may reflect a thyroid disorder (exophthalmos) or diabetes (retinopathy).

When the Examiner reaches Item 48 in the course of the examination of an applicant, it is recommended that the Examiner take a moment to review and determine if key procedures have been performed in conjunction with examinations made under other items, and to determine the relevance of any positive or abnormal findings.

III. DISPOSITION

The following is a partial list of conditions that warrant denial or deferral to the Aeromedical Certification Division, AAM-300. All disqualifying defects are subject to further FAA consideration.

A. Endocrine disorders

1. Acromegaly.

2. Addison’s disease.

3. Cushing’s disease or syndrome.

4. Diabetes insipidus.

5. Hypoglycemia, whether functional or a result of pancreatic tumor.

6. Hyperthyroidism.

7. Hypothyroidism. The use of thyroid replacement therapy following Rx of either hyperthyroidism or hypothyroidism is not disqualifying if the applicant appears clinically euthyroid pending receipt of confirmatory laboratory tests. Otherwise the Examiner should defer issuance, transmit the application electronically, and forward all reports to the Aeromedical Certification Division, AAM-300, for a determination.

8. Hyperparathyroidism.

9. Hypoparathyroidism.

10. Diabetes Mellitus. A blood glucose determination is not a routine part of the FAA medical evaluation for any class of medical certificate. However, the examination does include a routine urinalysis. (See Item 57). A medical history or clinical diagnosis of diabetes mellitus may be considered previously established when the diagnosis has been or clearly could be made because of supporting

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laboratory findings and/or clinical signs and symptoms. When an applicant with a history of diabetes is examined for the first time, the Examiner should explain the procedures involved and assist in obtaining prior records and current special testing. Applicants with a diagnosis of diabetes mellitus controlled by diet alone are considered eligible for all classes of medical certificates under the medical standards provided they have no evidence of associated disqualifying cardiovascular, neurological, renal, or ophthalmological disease. Specialized examinations need not be performed unless indicated by history or clinical findings. The Examiner should document these determinations on FAA Form 8500-8.

Applicants with a diagnosis of diabetes mellitus controlled by use of an oral hypoglycemic medication may be considered by the FAA for Special Issuance of a Medical Certificate (Authorization). Following initiation of oral medication treatment, a 60-day period must elapse prior to certification to assure stabilization, adequate control, and the absence of side effects or complications from the medication.

Initial certification decisions shall not be made by the Examiner. These cases will be deferred to the Aeromedical Certification Division, AAM-300. Examiners may be delegated authority to make subsequent certification decisions, subject to further Aeromedical Certification Division, AAM-300,

review and consideration.

The initial determination of eligibility will be made on the basis of a report from the treating physician. For favorable consideration, the report must contain a statement regarding the medication used, dosage, the absence or presence of side effects and clinically significant hypoglycemic episodes, and an indication of satisfactory control of the diabetes. The results of an A1C hemoglobin determination within the past 30 days must be included. Note must also be made of the absence or presence of cardiovascular, neurological, renal, and/or ophthalmological disease. The presence of one or more of these associated diseases shall not be, per se, disqualifying, but the disease(s) shall be carefully evaluated to determine any added risk to aviation safety.

Recertification decisions will also be made on the basis of reports from the treating physician. The contents of the report must contain the same information required for initial certification and specifically reference the presence or absence of satisfactory control, any change in the dosage or type of oral hypoglycemic drug, and the presence or absence of complications or side effects from the medication. In the event of an adverse change in the applicant’s diabetic status (poor control or complications or side effects from the medication), or the appearance of an associated systemic disease, an Examiner who has been given the authority to issue a certificate pending further review and consideration by the Aeromedical Certification Division shall defer

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certification to the Aeromedical Certification Division.

If, upon further review, it is decided that recertification is appropriate, the Examiner may again be given the authority to issue certificates (subject to the Aeromedical Certification Division’s review and consideration) based on data provided by the treating physician, including such information as may be required to assess the associated medical condition(s).

As a minimum, follow-up evaluations by the treating physician of the applicant’s diabetic status shall be required annually for all classes.

Airmen who are diabetics should be counseled by Examiners regarding the significance of their disease and its possible complications. They should be informed of the potential for hypoglycemic reactions and cautioned to remain under close medical surveillance by their treating physicians. They should also be advised that should their oral medications be changed or dosages modified, they should not perform airman duties until the treating physician has concluded that their conditions are under control and present no hazard to aviation safety. Airmen who use insulin for the treatment of their diabetics, may also be considered for medical certification.

The FAA has established a policy that permits the special issuance medical certification of insulin-treated applicants for third-class medical certification. (See Medical Certification of Insulin-Treated Diabetic Applicants, Appendix B, page 29).

B. General Systemic Findings

The following general systemic findings are disqualifying for Examiner issuance of a medical certificate.

Further consideration may be obtained by written appeal. Other general systemic conditions may also disqualify.

1. Body build: Any congenital or acquired defect that would adversely affect flying safety or endanger the individual’s well being if permitted to fly. Although obesity, in itself, is not disqualifying, related conditions or diseases may be.

2. Allergies: See Item 18.e.

3. Malignancies, except for minor skin lesions, are disqualifying until they are adequately treated and have been evaluated by the FAA. Surgery for cancer is not disqualifying, per se, unless a radical procedure results in a significant loss of functions or processes necessary to aviation safety.

When sufficient time has elapsed for recovery from the adverse effects of the eradication procedure, the applicant may receive FAA consideration.

A report from the treating physician should be submitted along with medical and surgical records. If the applicant is found qualified, the FAA will issue a medical certificate. Follow-up reports may be required at specified intervals depending upon the type and site of the malignancy, post-operative progress, prognosis,

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metastases, lapse of time since surgery or related symptoms, use of medication, and other pertinent data.

4. Acquired Immunodeficiency Syndrome (AIDS). Applicants who are infected with the Human Immunodeficiency Virus (HIV), who do not have a diagnosis of AIDS and who are without manifestations of disease, whether or not they are using medication, may be considered for medical certification if otherwise qualified. (See Protocol for Human Immunodeficiency Virus (HIV) Related Conditions, Appendix B, page 31).

END OF CHAPTER 3 | AME GUIDE

AME GUIDE Table of Contents | Index | Chapter 1 2 3 4

Guide for AME’s | Ch. 3 Pg. 35

Contact us at 1-405-787-0303 or by email here to confidentially discuss your FAA medical issues.

Contact us at 1-405-787-0303 or by email here
to confidentially discuss your FAA medical issues.