PHYSICIAN TO THE PRESIDENT THE WHITE HOUSE 16 February 2023 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 remains fit for duty, and fully executes all of his responsibilities without any exemptions or accommodations. Thave conducted a comprehensive review of President Biden’s medical history and a detailed physical examination. This physical has included specialty consultation with several of our Presidential Specialty Consultants from the Walter Reed National Military Medical Center. These specialties have included Optometry, Dentistry, Orthopedics (Foot and Ankle), Orthopedics (Spine), Podiatry, Physical Therapy, Neurology, Cardiology, Radiology and Dermatology. 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 19 November 2021. Today's memorandum speaks to his current health and fitness and addresses any interval change. Interval History: The most notable interval history for this past year was the President’s very extensively reported upper respiratory infection from SARS-CoV-2 (COVID-19). His initial infection ran from 21 July 2022 through 27 July 2022. He then experienced rebound COVID-19 positivity which started on 30 July 2022 and he tested negative on 6 August 2022. Fortunately, having been fully vaccinated and twice boosted at the time of initial infection, the President experienced only mild symptoms, consisting mostly of a deep, loose cough and hoarseness. He responded very well to standard, outpatient therapy, to include the anti-viral medication, Paxlovid. His vital signs remained normal throughout his illness. Most importantly, his oxygenation remained excellent on room ait. His pulse oximetry never fell below 97%. The President experienced rebound positivity several days after testing negative, as has been welldocumented. Again, his course remained mild. During his infection, the President was able to continue the business of the American people, working from the Executive Residence. He isolated in accordance with Centers for Disease Control ‘and Prevention (CDC) recommendations. He made it a very deliberate priority to protect any of the Executive Residence, White House, Secret Service and other staff whose duties required any (albeit socially distanced) proximity to ‘The President has not experienced any residual symptoms which may be considered to be “Long COVID”. He has received his Bivalent COVID vaccine. Current Health: President Biden is an active 80-year-old white male who is currently being treated for the following: 1. 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 69 and no acute ST or T wave changes. Echocardiogram demonstrates normal ventricular contractility (function), with no signs of heart failure. Left ventricular Ejection Fraction was 55-60%, Excellent functional capacity. « 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. 2. 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 115 mg/dL, Triglycerides 87 mg/dL, High Density Lipoprotein (HDL) 46 mg/dL, Low Density Lipoprotein (LDL) 58 mg/dL 3. Gastroesophageal Reflux, stable + 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. He underwent an aggressive workup which was detailed on the November 2021 health summary. My original assessment that gastroesophageal reflux is the source of the President's throat clearing and coughing was supported by the findings and by expert consultation,+ Lung examination, oxygen saturation and chest imaging remain entirely normal. ‘* He will continue his current regimen of the acid blocker, famotidine (Pepcid). 4. 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 fluticasone/azelastine (Dymista) nasal spray and over-the-counter fexofenadine (Allegra) for these symptoms. 5. 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 stiffness 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, but did 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. ‘* Examination this year was unchanged, with the exception of possibly tighter hamstrings and calves. «* 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. This exam did again support a mild peripheral neuropathy in both feet. He did not demonstrate any motor weakness, but a subtle difference in heat/cold sensation could be elicited. * A combination of significant spinal arthritis, mild post-fracture foot arthritis and a mild sensory peripheral neuropathy of the feet are the explanation for the subtle gait changes which I was investigating. This assessment is unchanged. « Physical Therapy and exercise prescription will continue to focus on general flexibility and proprioceptive maintenance maneuvers. 6. Mild Sensory Peripheral Neuropathy of Feet, stable « Neurology, Orthopedic (Foot & Ankle) and Podiatry consultations are reviewed and appreciated. © A finding of mild peripheral neuropathy is noted as above. His symptoms have not progressed, and his exam is actually a bit improved, in that the area of subtle heat/cold sensation deficit seems less pronounced and has decreased in size. © The most common cause of peripheral neuropathy is diabetes, The President does not have diabetes (Hemoglobin A1C 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 function also remains normal, + In up to 46% of cases, especially when the symptoms are mild such as causes are not identified. * Custom orthotics have been prescribed to optimize foot biomechanics. this patient, specific 7. 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. As was done in November 2021, several small areas of actinic change on his face and head were treated with liquid nitrogen cryotherapy. ‘ One small lesion on the President's chest was excised today and sent for traditional biopsy. Results are pending, 8. Optometry Surveillance, routine ‘* Optometry consult is reviewed and appreciated. ‘* The President underwent routine eycloplegic (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 obiained and contact lens prescriptions were updated, 9.Dental Surveillance, routine * Dental consult is reviewed and appreciated. * Routine dental exam, with X-rays, revealed no dental issues requiring any interventions. Medications/Allergies Apixaban (Eliquis) Rosuvastatin (Crestor) Fluticasone/azelastine (Dymista) nasal spray Fexofenadine (Allegra) (over-the-counter) Famotidine (Pepcid) (over-the-counter) Patient has no known medication allergies. Social History: ‘The President does not use any tobacco products, does not drink alcohol, and he continues to work out at least five days per week.2 inches, Weight: 178 Ibs, Body Mass Index (BMI): 24.1 Blood Pressure: 128/76, Pulse: 69, Respiratory Rate: 15, Temperature: 98.6 F, Pulse oximetry: 98% Physical exam is 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. Extremities have a full range of motion. Strength and reflexes are all normal and symmetrical. Cranial nerves and vestibular function are normal. No bradykinesia or start hesitation. No resting tremor. No rigidity. Mildly decreased heat/cold sensation in both feet. Patient does have several areas of lentigo and actinic changes. One small lesion on his chest was sent for biopsy. not specifically mentioned above 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. Vitamin D level was normal. Magnesium level was normal, Summary This patient's current medical considerations are detailed as above. They include a-fib with normal ventricular response, hyperlipidemia, gastroesophageal reflux, seasonal allergies, spinal arthritis and mild sensory peripheral neuropathy of the feet. For these, he takes three common prescription medications and two common over-the-counter medications. President Biden remains a healthy, vigorous, 80-year-old male, who is fit to successfully execute the duties of the Presidency, to include those as Chief Executive, Head of State and Commander in Chief. Respectfully submitted, ZZ : 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