• There is no past medical history of hypertension, diabetes, tuberculosis, sexually transmitted disease, or stroke. The President benefits from a “low” to “very low” (favorable) coronary artery disease risk profile with a favorable family medical history, absence of modifiable risk factors; superior fitness, favorable CAD markers (e.g. CRP, lipids) and functional studies (“stress echocardiogram”), and “minimal/mild” coronary artery calcification noted on anatomic study (coronary artery computed tomography, 12/2004).
• Erythema migrans consistent with early, localized Lyme disease, treated, with complete resolution and without recurrence, 8/06.
• Seborrheic keratosis.
• Actinic keratoses identified and treated with liquid nitrogen.
• Telangiectasias, nasal bridge, consistent with solar damage; treated 8/03.
• Vasovagal syncope, 1/02; solitary episode with identifiable precipitating event superimposed on longstanding, non-pathologic sinus bradycardia (consistent with a conditioned heart); evaluation 1/02, no sequelae, and no recurrence since 1/02.
• Adenomatous colonic polyps (5 tubular adenomas, each < 1.0 cm without advanced features) removed on surveillance colonoscopy 7/07. Repeat colonoscopy is indicated in 3 years.
• Mild high frequency hearing loss documented and stable on prior exams; speech frequencies excellent. Currently no symptoms.
• History of seasonal allergic rhinitis; asymptomatic this spring with preventive seasonal use of nasal corticosteroid spray.
• The President has a history of activity-related injuries as noted below, which resolved without sequelae and do not impact his current duties. He continues a vigorous aerobic, weight training, and flexibility program.
• Musculoskeletal low back pain secondary to heavy lifting and tight “hamstrings”; fully evaluated in 1990; asymptomatic due to current exercise and flexibility program.
• Intermittent bilateral anterior knee pain, activity-related, with a left medial meniscal injury and subsequent surgical repair in 1997. Orthopedic and radiographic re-evaluation in 12/03 confirmed an old incomplete tear of the PCL of the right knee with resultant patello-femoral chondromalacia, post-traumatic degenerative changes, and asymptomatic medial meniscal damage, all most consistent with a remote athletic injury and physical activity. Symptoms resolved with quadriceps strengthening, cross-training (biking), and elimination of routine impact exercises (e.g. running) from his routine.
• Right “calf” running injury (strain/tear), 4/03, most consistent with overuse. Symptoms resolved.
• Minor abrasions and lacerations secondary to injuries sustained while biking, all healed without sequelae.
• Gastroesophageal reflux with well-defined triggers, 2005, without recurrence.
• Vitreous floaters, infrequent, evaluated by retinologist 3/06; examination normal for age (non-pathologic age-related changes only).
• Mild hyperopic astigmatism/presbyopia, fully correctable. Uses reading glasses as-needed
• Blood transfusions: none.

• Appendectomy 1956
• Left medial menisectomy as above, 3/97

• The President takes a daily multi-vitamin. He does not routinely use prescription medications.

• The President’s immunizations are current for worldwide travel.

• Tobacco: An occasional cigar
• Alcohol: None
• Caffeine: Diet sodas and coffee
• Exercise: The President exercises six times per week. Workouts include cycling, elliptical trainer, resistance training, and flexibility exercises.
• Other: A viral illness prompted rearrangement of the President’s schedule at a morning session of the G8 in June. The President has not otherwise missed work due to illness since his last physical exam.

ENT (ears, nose, and throat): Physical examination of the head, neck, and thyroid are normal except for a serous otitis media as well as signs and symptoms consistent with maxillary sinusitis and recovering mild vestibular neuronitis. Audiogram shows bilaterally symmetric high frequency sensorineural hearing loss consistent with age and without significant change from previous exams. Thyroid function tests were normal.

Eyes: No ocular pathology was noted on dilated ophthalmoscopic examination. Visual fields were normal. Distant visual acuity was 20/20. Corrected near visual acuity was 20/20 in both eyes (the President uses reading glasses as needed). Intraocular pressures were normal bilaterally.

Neurologic exam: Comprehensive examination normal.

Pulmonary: Normal.

Gastrointestinal: Normal. Colonoscopy was last performed in July 2007. No recurrence of previously described symptoms consistent with occasional gastroesophageal reflux. Abdominal examination normal.

Cardiology: Physical examination of the circulatory system was normal. The resting EKG revealed sinus bradycardia consistent with previous exams and aerobic conditioning. Fasting lipid panel: total cholesterol: 170 (last year 174; “desirable”<200); HDL: 51 (last year 60; >40); LDL: 106 (last year 101; "optimal"<100, “desirable”/“near optimal”<130); total cholesterol/HDL ratio 3.3 (last year 2.9); Triglycerides: 61 (last year 71; <150). hsCRP: < 0.012 (range 0.0-0.5). Homocysteine: 12.5 (range 7.6-20.8).

The President underwent Balke protocol exercise treadmill testing (ETT) with echocardiogram. He exercised for a total of 25:01 minutes achieving a maximum heart rate of 184 bpm with a 1-minute recovery of 150 bpm (34 beat differential). No signs or symptoms of cardiovascular pathology were noted. Stress echocardiogram was normal.

Dermatology: Seborrheic keratoses and lesions consistent with solar damage (e.g. telangiectasias) noted as in past. History of past actinic keratosis was noted but none discovered on this exam.

Musculoskeletal: General musculoskeletal survey was unremarkable.

Genitourinary System: Normal. PSA was 0.6 (normal < 4.0).

Laboratories

The President remains in excellent health and is “fit for duty”. All data suggest that he will remain so for the duration of his Presidency. Based on an overview of his examination and history the following clinical diagnoses are made:

• Low” to “very low” coronary artery disease risk profile. Coronary artery disease (CAD) "activity-marker" evaluation (including C-reactive protein, homocysteine, and lipids), and “functional” studies (exercise treadmill test) stratify the President to a “low” to “very low” coronary risk category. Continued “therapeutic lifestyle measures” (i.e. reduced intake of saturated fat and cholesterol, regular physical activity, and weight control) are appropriate.
• Sinus bradycardia, asymptomatic, non-pathologic, and consistent with a conditioned heart.
• History of vasovagal syncope without pathology, sequelae, or recurrence.

2. History of vitreous floaters, infrequent, nonpathologic, normal for age. Mild hyperopic astigmatism/presbyopia, fully correctable.

3. Seasonal allergic rhinitis, well-controlled.

4. Serous otitis media and maxillary sinusitis with mild viral vestibular neuronitis, recovering.

5. History of mild high frequency sensorineural hearing loss unchanged from examinations.

6. History of gastroesophageal reflux without recurrence.

7. History of colonic adenomas, removed 7/07. Repeat colonoscopy indicated in 3 years.

9. History of activity-related musculoskeletal injuries currently without symptoms limitations

10. Skin lesions consistent with solar damage. Recommend continued sun-protection measures (e.g. sunscreen, wide-brimmed hats, etc.) Seborrheic keratoses—treatment not indicated nor requested. History of early, localized Lyme disease, treated without recurrence or sequelae. Recommend standard precautions in endemic areas.