w PHYSICIAN TO THE PRESIDENT THE WHITE HOUSE 28 February 2024 MEMORANDUM FOR: KARINE JEAN-PIERRE, ASSISTANT TO THE PRESIDENT AND. WHITE HOUSE PRESS SECRETARY FROM KEVIN C, O'CONNOR, D.O., FAAFP PHYSICIAN TO THE PRESIDENT SUBJECT: President Biden’s current health summary As requested by the patient, the following is a summary of the current health status of President Joseph R. Biden. The President feels well and this year's physical identified no new concems. He continues to be fit for duty and fully executes all of his responsibilities without any exemptions or accommodations. ‘As in previous years, I have conducted a comprehensive review of President Biden's medical history and performed a detailed physical examination. This physical has again included specialty consultation with several of our Presidential Specialty Consultants from the Walter Reed National Military Medical Center. These specialties have included Optometry, Dentistry. Orthopedies (Foot and Ankle), Orthopedics (Spine), Physical Therapy, Neurology, Sleep Medicine, Cardiology. Radiology and Dermatology. Each of these specialists have independently reviewed the chart, examined the President, and coneur with my findings and recommendations. Ihave also solicited feedback from my respected colleagues ~ the other physicians in the White House Medical Unit, who see the patient every day. Each of these doctors has reviewed my report for accuracy. My conclusions have been further informed through discussions with several of my fellow professors from the George Washington University School of Medicine and Health Sciences. This document updates my last statement, from 16 February 2023. Today's memorandum speaks to the President's current health and fitness and addresses any interval change. Interval History: As per my 3 March 2023 follow up memorandum. the skin lesion which was removed from the President's chest during last year’s annual health assessment was found to be basal cell carcinoma. No further treatment for that lesion was required. Basal cell carcinoma lesions do not tend to “spread” or metastasize. as some more serious skin cancers such as melanoma or squamous cell carcinoma are known to do. They do, however, tend to increase in size, and may become moredifficult to easily remove as they do so. For this reason, they should be addressed as they are identified. ‘The most notable interval history for this past year was the incorporation of Positive Airway Pressure (PAP) into the President's sleeping routine. As was reported in his 2008 medical records release and again in my 15 December 2019 report, the President had experienced symptoms consistent with Obstructive Sleep Apnea (OSA) in the past, but his symptoms improved significantly after his sinus and nasal passage surgeries. Given the importance of efficient sleep for anyone, but certainly for a senior executive, we revisited the issue this past spring, and conducted a formal sleep study. This study confirmed my suspicion that the President would benefit from optimizing his sleep efficiency with PAP. Obstructive Sleep Apnea (OSA) effects over 30 million Americans and is readily treated with Positive Airway Pressure (PAP) as first line therapy. Most people do experience some difficulties getting used to falling asleep while wearing a mask on their face, as well as with keeping iton throughout the night. This is reasonably anticipated and, in fact, should be expected. The President had a very similar experience. But with trials of several different masks, we have been able to identify a of couple products which fit him very comfortably and effectively. He has been remarkably committed to sticking with therapy and uses PAP successfully almost every night, for ‘most or all of the night, ‘The other significant interval history this past year was a dental urgency which we dealt with in June, He was able to receive an initial root canal procedure the same day. with definitive specialized endodontic follow up the next day. The President only required a local numbing medication. All interventions were conducted in the White House Dental Operatory. He tolerated the procedures well, and there were no complications. Current Health: President Biden is an active 81-year-old white male who is currently being treated for the following: 1, Obstructive Sleep Apnea (OSA), New, stable ‘* Sleep Medicine consultation is reviewed and appreciated. ‘* Polysomnography confirmed suspected diagnosis. '* Data from Positive Airway Pressure (PAP) surveillance confirms complete treatment when therapy is in place. + This patient has demonstrated excellent response to PAP and is diligently compliant with therapy. 2. Non-Valvular Atrial Fibrillation (A-fib), stable « Cardiology consultation is reviewed and appreciated. « Persistent a-fib, with a normal ventricular response. He remains completely asymptomatic,‘* Electrocardiogram (EKG) confirms this rhythm, with a rate of 77 on no rate controlling agents, normal intervals and normal QRS and ST-T wave morphology. + This patient has never required any medication or electrical treatments to address either his rate or his rhythm, ‘© He remains stable on apixaban (Eliquis) for standard anticoagulation, 3. Hyperlipidemia, stable © Cardiology consultation is reviewed and appreciated ‘+ The President’s lipid levels remain remarkably low on his current regimen of rosuvastatin (Crestor). «Lipid Panel: Total Cholesterol 122 mg/dL, Triglycerides 90 mg/dl., High Density Lipoprotein (HDL) 45 mg/dL, Low Density Lipoprotein (LDL) 68 mg/dL 4, Gastroesophageal Reflux, stable + Gastroenterology consultation is reviewed and appreciated. « President Biden experiences occasional symptoms of gastroesophageal reflux, primarily having to clear his throat more often. This may also contribute to occasional cough and sinus congestion. His symptoms are typically exacerbated shortly after meals. This has been worked up extensively during previous health assessments. ‘© He will continue his current regimen of the acid blocker, famotidine (Pepeid) in the momning. We did add esomeprazole (Nexium) in the evening, for even better acid control. He has experienced significant improvement in his symptoms this year. 5, Seasonal Allergies, stable + This patient has dealt with seasonal allergies and sinus congestion for most of his life. ‘* His sinus symptoms have improved after several sinus and nasal passage surgeries, but he still uses flutieasone/azelastine (Dymista) nasal spray and over-the-counter fexofenadine (Allegra) for these symptoms. 6. — Stiffened Gait (Moderate to Severe Degenerative Osteoarthritic Change/Spondylosis), stable * Orthopedics (Spine), Orthopedics (Foot & Ankle), Podiatry. Neurology, Radiology and Physical Therapy consultations are reviewed and appreciated. # Asa part of the November 2021 physical, I noted that the President was demonstrating a perceptibly stiffened ambulatory gait as compared to before his foot fracture. I assembled a team comprised of spine, foot and ankle, radiology, physical therapy and movement disorder neurologic specialists to carefully examine and assess the President, © After careful analysis of the patient’s history, findings on detailed physical exam and review of radiologic imaging, the team concluded that much of his stiffhess is in fact a result of degenerative (wear and tear") osteoarthritic changes (or spondylosis) of his spine. Moderate to severe spondylosis was demonstrated at multiple levels. Repeat imaging was obtained during today’s visit. The President’s arthritic changes remain moderate to severe, but stil! do not result in nerve root compression significant enough that they would warrant any specific treatment.+ The President’s gait remains stiff, but has not worsened since last year. « Spinal examination this year was clinically unchanged. Dynamic radiographic exam. demonstrates mildly decreased range of motion, consistent with his known arthritic changes. * An extremely detailed neurologic exam was again reassuring in that there were no findings which would be consistent with any cerebellar or other central neurological disorder, such as stroke, multiple sclerosis, Parkinson's or ascending lateral sclerosis, nor are there any signs of cervical ‘myelopathy. This exam did again support a finding of peripheral neuropathy in both feet. No motor ‘weakness was detected. He exhibits no tremor, either at rest or with activity. He demonstrates excellent fine motor dexterity, But a subtle difference in heat/cold sensation could be elicited as it was last year. This heat/cold sensation deficit was detected a couple inches higher on his ankle/calf this year, which is not unexpected. There may, in fact, be day to day subjective variation of these findings, as during last year’s exam, this area of sensation deficit was actually found to be smaller than the year before. + A combination of significant spinal arthritis, post-fracture foot arthritis and a sensory peripheral neuropathy of the feet are the explanation for the subtle gait changes which I was investigating. This assessment is unchanged. « The President did note some increased left hip discomfort with activity recently, Clinical exam was normal except for decreased range of motion. Radiographs reveal mild arthritic changes, This is most certainly also contributing to his stiffened geit, No additional treatment is warranted, other than his ongoing physical therapy. * Physical Therapy and exercise prescription will continue to focus on general flexibility and proprioceptive maintenance maneuvers. These focus on lower extremity strengthening and core stability. We have added a more intensive stretching routine to the President's exercise prescription, and he has been regularly participating in this program at least four to five times a week. 7. Sensory Peripheral Neuropathy of Feet, stable * Neurology, Orthopedic (Foot & Ankle) consultations are reviewed and appreciated. ‘* A finding of peripheral neuropathy is noted as above. His symptoms have not progressed, but the area of subtle heat/cold sensation deficit detected on examination does seem to be slightly increased in size. The most common cause of peripheral neuropathy is diabetes. ‘The President does not have diabetes (Hemoglobin AIC and fasting blood glucose are both normal). © Other common etiologies for this include alcoholism, vitamin B12 deficiency and thyroid disease The President does not consume alcohol. His B12 levels are normal and his thyroid funetion tests (ESHI/T4) remain normal, « In up to 46% of cases, especially when the symptoms are mild such as with this patient, specific causes are not identified. 8. Skin Cancer Surveillance, routine ‘* Dermatology consultation is reviewed and appreciated. « Itis well-established that President Biden did spend a good deal of time in the sun in his youth. He has had several localized, non-melanoma skin cancers removed with Mohs surgery before hestarted his presidency. ‘These lesions were completely excised, with clear margins, Total body skin exam was performed for dermatologic surveillance. # No areas were detected which would require biopsy. 9. Optometry Surveillance, routine © Optometry consult is reviewed and appreciated. + The President underwent routine eycloplegie (dilated) eye examination. His overall eye health is reassuring. There were no signs of glaucoma, retinopathy, macular degeneration or significant cataracts. Current optometric refraction was obtained and contact lens prescriptions were updated. 10. Dental Surveillance, routine * Dental consultation is reviewed and appreciated. + Root canal procedure required no follow up treatment. Routine dental exam, with X-rays, revealed no dental issues requiring any immediate interventions. Medications/Allergies: Apixaban (Eliquis) Rosuvastatin (Crestor) Fluticasone/azelastine (Dymista) nasal spray Fexofenadine (Allegra) (over-the-counter) Famotidine (Pepcid) (over-the-counter) Esomeprazole (Nexium) (over-the-counter) Patient has no known medication allergies. Social History: ‘The President has been happily married for 46 years. He does not use any tobacco products, does not drink alcohol, and he continues to work out at least five days per week, Physical Exam: Height: 72 inches, Weight: 178 Ibs, Body Mass Index (BMI): 24.1 Blood Pressure: 132/78, Pulse: 64, Respiratory Rate: 14, Temperature: 98.6 F, Pulse oximetry: 98% Physical exam is essentially unchanged from baseline, Head, ears, eyes, nose and throat are normal, He has no enlarged lymph nodes or goiter. Lungs are clear. Heart demonstrates a regular pulse rate and characteristically “irregularlyirregular” rhythm. He has no significant murmurs, gallops or rubs. Abdomen is soft, non= distended. Liver and spleen are normal size. Patient has no external hernias. Detailed neurologic exam as above, Cranial nerves and vestibular function are normal. No bradykinesia or start hesitation, No tremor. No cogwheeling. Mildly decreased heat/cold sensation in both feet. Extremities have a full range of motion (with above noted tightness of hamstrings/calves). No clubbing, cyanosis or edema. Patient does have several areas of lentigo and actinic changes. Labs not specifically mentioned abov. Comprehensive metabolic panel (CMP) was normal, to include electrolytes, creatinine, blood urea nitrogen, protein and liver enzymes. Urinalysis was normal, no glucose, protein or blood. Complete blood count (CBC) was normal, No signs of anemia. Vitamin D level was normal. Homocysteine level was normal. Folate was normal. Creatine Kinase was normal. Magnesium level was normal. jummary. This patient’s current medical considerations are detailed as above, and remain stable and well-controlled. They include obstruetive sleep apnea, a-fib with normal ventricular response, hyperlipidemia, gastroesophageal reflux, seasonal allergies, spinal arthritis and sensory peripheral neuropathy of the feet. For these, he takes three common prescription medications and three common over-the-counter medications. President Biden is a healthy, active, robust 81-year-old male, who remains fit to successfully execute the duties of the Presidency, to include those as Chief Executive, Head of State and Commander in Chief. Respectfully submitted, LEE : Kevin C, O'Connor, D.O., FAAFP Physician to the President The White House Associate Professor, The George Washington University School of Medicine & Health Sciences