AME Case Analysis & Practical Application 2 — Questions and Answers
Question 1: A 45-year-old commercial pilot presents for a Second-Class medical. His blood pressure reads 158/96 mmHg. What is the appropriate AME action?
- Issue the certificate; elevated BP is not disqualifying for Second-Class
- Defer to AMCD; any elevation above normal is disqualifying
- Allow a repeat measurement after the applicant rests; if still elevated, evaluate further (Correct answer)
- Issue with a limitation requiring annual cardiac evaluation
Correct answer: Allow a repeat measurement after the applicant rests; if still elevated, evaluate further
FAA protocol allows AMEs to take multiple blood pressure readings and allow the applicant to rest before making a determination. Persistent elevation may require deferral or additional evaluation.
The FAA uses approximately 155/95 mmHg as a guideline threshold, though uncontrolled hypertension becomes a general medical condition concern. AMEs should take readings at the start and end of the exam, allow rest if initial readings are elevated, and document all measurements. Applicants with persistently elevated BP may be issued a certificate if already on treatment with controlled BP, or deferred to AMCD if not controlled.
Question 2: During an exam, the AME notices the applicant has a mild tremor in both hands. The applicant is 60 years old and reports it as 'essential tremor.' What is the correct course of action?
- Issue the certificate; essential tremor is not listed as disqualifying
- Perform a standard neurological exam and defer to AMCD with findings if the tremor could affect duties (Correct answer)
- Deny issuance; any tremor in a pilot over 55 is disqualifying
- Issue with a requirement for yearly neurology review
Correct answer: Perform a standard neurological exam and defer to AMCD with findings if the tremor could affect duties
Essential tremor is not automatically disqualifying, but the AME must assess functional impact. If the tremor could impair the safe performance of duties, the case should be deferred to the AMCD.
14 CFR 67.109/209/309 require the AME to evaluate whether any neurological condition could interfere with the safe performance of airman duties. Essential tremor is common in older individuals, but its severity and functional impact must be assessed. A thorough neurological exam including coordination and fine motor testing is documented on the 8500-8. If the tremor appears mild and non-functional, issuance may proceed. If there is functional concern, deferral to AMCD with a neurology consultative report is appropriate.
Question 3: An applicant discloses a history of alcohol use disorder 4 years ago and has been in continuous sobriety. How should the AME proceed?
- Deny issuance; alcohol use disorder history is permanently disqualifying
- Issue the certificate; 4 years of sobriety is sufficient
- Defer to AMCD; substance use disorder history requires FAA evaluation and potential HIMS AME involvement (Correct answer)
- Issue a Third-Class certificate only, with a limitation for alcohol monitoring
Correct answer: Defer to AMCD; substance use disorder history requires FAA evaluation and potential HIMS AME involvement
History of alcohol use disorder triggers the HIMS (Human Intervention Motivation Study) AME process. The case must be deferred to AMCD unless the AME is a qualified HIMS AME with an established Authorization.
Alcohol use disorder is managed through the FAA's HIMS program, which involves specialized HIMS AMEs and specific evaluative requirements including AUDIT-C, SASSI assessment, liver function tests, and sometimes inpatient evaluation reports. A standard AME who is not HIMS-designated must defer such applicants to the AMCD, which will route them to a HIMS AME. The applicant may ultimately qualify with demonstrated sustained sobriety and compliance with FAA monitoring requirements.
Question 4: A 52-year-old ATP applicant presents for a First-Class medical renewal. His resting ECG shows a new right bundle branch block (RBBB) compared to his prior exam. What should the AME do?
- Issue the certificate; isolated RBBB is a normal variant
- Defer to AMCD; new RBBB requires cardiology evaluation before issuance (Correct answer)
- Repeat the ECG immediately and issue if the RBBB is confirmed isolated
- Issue with a notation and schedule a follow-up in 6 months
Correct answer: Defer to AMCD; new RBBB requires cardiology evaluation before issuance
A new RBBB on ECG, particularly in a pilot over 40, must be deferred to the AMCD for cardiology evaluation, as it may indicate underlying structural or ischemic cardiac disease.
New right bundle branch block requires cardiology evaluation to exclude underlying coronary artery disease, cardiomyopathy, or pulmonary hypertension before a First-Class certificate can be issued. AMEs must defer such findings to the AMCD, which typically requires a cardiology consultation, exercise stress testing, and possibly echocardiography. Isolated RBBB in young individuals may be a normal variant, but in a 52-year-old ATP applicant, the risk of an underlying condition is sufficient to mandate full evaluation.
Question 5: An applicant presents with controlled Type 2 diabetes managed with metformin alone, with a recent HbA1c of 6.4%. What is the appropriate certification action under current FAA CACI policy?
- Deny issuance; any diabetes is disqualifying without special issuance
- Issue the certificate; metformin-controlled diabetes meeting CACI criteria qualifies for AME issuance (Correct answer)
- Defer to AMCD; all diabetics require Authorization regardless of treatment
- Issue only a Third-Class certificate
Correct answer: Issue the certificate; metformin-controlled diabetes meeting CACI criteria qualifies for AME issuance
Per current FAA CACI criteria, Type 2 diabetes controlled with metformin (a non-hypoglycemic agent) meeting HbA1c and other criteria can be issued by the AME without AMCD deferral.
The FAA has established CACI criteria for diabetes mellitus not requiring insulin. If the applicant takes only non-hypoglycemic oral agents such as metformin, SGLT-2 inhibitors, or DPP-4 inhibitors, and meets defined thresholds including HbA1c at or below 9% with no hypoglycemic episodes and no end-organ complications, the AME can issue without deferral. Applicants on sulfonylureas or insulin require special issuance review.
Question 6: During an otoscopic examination for a First-Class applicant, the AME observes a large tympanic membrane perforation. What is the required next step?
- Issue the certificate if audiometric testing meets standards
- Defer to AMCD with ENT specialist report (Correct answer)
- Deny issuance; perforation is categorically disqualifying
- Issue with a waiver for ENT follow-up within 60 days
Correct answer: Defer to AMCD with ENT specialist report
A tympanic membrane perforation can affect Eustachian tube function and pressure equalization, critical for flight safety. The AME must defer to AMCD with an ENT specialist evaluation.
Tympanic membrane perforation raises concerns about middle ear pressure equalization, susceptibility to otitis media, and ability to perform the Valsalva maneuver. 14 CFR 67.105/205/305 require adequate ear function, and AMEs must defer applicants with significant otologic findings to AMCD after obtaining an ENT specialist evaluation. If the perforation is small, chronic, and functionally non-significant with documented audiometric standards met, special issuance may be possible.
AME Case Analysis & Practical Application 2
A 45-year-old commercial pilot presents for a Second-Class medical.
His blood pressure reads 158/96 mmHg.
What is the appropriate AME action?