# Press Briefing by Doctor Connie Mariano, January 12, 2001

Bethesda Naval Hospital, Bethesda, Maryland
3:50 P.M. EST
MR. SIEWERT: Welcome back to Bethesda Naval Hospital for President Clinton's seventh visit here. This includes six physical examinations, as well as one hospitalization for tendon repair in 1997.
Let me begin by saying thank you very much to Admiral Martin, the Commander of the Bethesda Naval Hospital, and Bethesda's Public Affairs Office, including Commander Ed Austin, Kevin Sforza, and their team, for taking care of all the press today. Most of all, we want to thank the doctors, the nurses, the corpsmen and all the staff who participated in today's visit.
The President is very grateful, as he told you on his way out, for the outstanding care he has received here over the years at Bethesda Naval Hospital. There was a very moving military tribute to him as he left upstairs, and he appreciated it very much.
Today's exam took about three hours to complete. The highlights of those findings are being released to you now on paper, and we'll make those available back at the White House, as well. Admiral Connie Mariano, the President's personal physician, will go over the key features of today's visit. The President is very appreciative for the work she and her team have done at the White House, a grueling schedule that the President put them through, and they've always been there to take care of him through good times and bad.
After her report we'll go off camera and we'll have five or ten minutes of questions, and then we'll be done. Before I begin, let me just say, the President told us before he left that he's looking forward to getting back to civilian life where he might have a slightly more regular schedule, be able to exercise a little more regularly, take up running again and get himself in tip-top physical shape. But as for his shape today, it's very good, and I'll let Dr. Connie Mariano run you through that.
Thanks.
DR. MARIANO: Thank you, Jake. Good afternoon.
President Clinton underwent his final exam today; he passed. This was his sixth physical exam on the President and, as in the past, President Clinton was evaluated by a panel of medical experts who are all board-certified in their specialties. I'd like to briefly name each one of them now and as I name them, if they could step forward to be acknowledged.
Our first member of the board is Dr. James Suen, Professor and Chairman of the Department of Otolaryngology at the University of Arkansas; Dr. David Leonard, from Bethesda Department of ENT; Captain Richard Morrissey, the Chairman of Bethesda Department of Cardiology; Captain James Butler, the Chairman of Bethesda Department of Gastroenterology; Dr. David Corbett, the retired Chairman of Bethesda Department of Dermatology, and now in private practice; Commander Francis McGuigan, a orthopedic surgeon from Bethesda Department of Surgery; Captain Robert Kellogg, the Chairman of Bethesda Department of Physical Therapy; Dr. Talal N'souli, Associate Professor of Allergy and Immunology at Georgetown University Hospital; Captain Paul Christenson, Chairman of Bethesda Department of Urology; Commander Craig Williams, the Navy Specialty Advisor for Podiatry; and Captain Sushil Jain, the head of Bethesda Department of Optometry.
Thank you, Doctors.
With the President's consent, I have released a report summarizing the medical findings from today. I would like to go over briefly that report and, again, the details are to be released very shortly with my report. Let's start off with vital statistics.
Our 54-year-old President weighed in at 214 pounds, on his 6'2" frame, and this weight is actually unchanged from last year's physical. It falls within the normal range of 190 to 220 for a man of his height.
Highlights from his blood tests include a total cholesterol that is elevated this year, to 233 -- 233. The triglyceride was 52; the HDL was 46. But the physicians were concerned about the elevated LDL or unhealthy cholesterol of 177, with a ratio of 5.1. The cholesterol and LDL values, again, we noted are elevated over last year's results and we recommended in addition to diet and exercise, we have started the President on medications to lower his cholesterol.
The President's chronic allergies were also evaluated today and, as you know, he has been receiving allergy shots every seven to 10 days since he's been coming to the White House. His allergist has recommended obtaining repeat skin testing in the future if he should discontinue those allergy shots.
The President's recurrent bouts of hoarseness were well controlled over this last year. He has had not very many episodes have been noted. His vocal cords were visualized and they were found unchanged from previous exams. The only thing we've done with his medications regarding his gastro-esophageal reflux disease, made them a more simplified regimen because after January 20th, he will be in charge of taking his own medications.
During the dermatology evaluation, the President's acne rosacea appeared very well controlled. He did not have any actinic skin lesions that he had had in the past so he did not require any liquid nitrogen treatments. But the dermatologist did not a small, suspicious skin lesion on the President's back and that lesion was biopsied. The results should be available within a week and we will definitely inform you of those results when they do come in.
The President's eye examination consisted of the updating of his reading glass prescription and the total eye exam was found to be normal, including a checkup for glaucoma.
And then, finally, with no history of coronary heart disease and five previous normal exercise treadmill tests, we elected not to perform another treadmill test, we elected not to perform another treadmill test again today. The President did undergo a routine ultrasound of his heart, and this was compared to his baseline ultrasound performed in 1994, and that was -- to moderate any questions.
Thank you.
MR. SIEWERT: This portion, I think, of the briefing will be off camera.

## Q Doctor, can you talk a little bit about -- (inaudible) -- can you tell us what that means --

    DR. MARIANO: I'm going to ask Dr. David Corbett, the President's dermatologist, to comment, because he noted the lesion and performed the biopsy.
    Dr. Corbett?
    DR. CORBETT: The President had a small flat spot on his back that was a little pearly, looked like a -- very suspicious for a basal cell skin cancer, a basal cell carcinoma, the most common type of skin cancer. It's a little locally-growing type of skin cancer, not a threat to his health or anything, a very small spot, if it turns out to be that.

## Q And you will find out next week --

    DR. CORBETT: Correct. We took tissue to biopsy that. It goes to the pathologist where it's processed. They'll look at it under the microscope and tell us for sure whether it was or not.

## Q Was it something that he could see or --

    DR. CORBETT: No, it was nothing that he had noticed.

## Q If it is found to be cancerous, what will be --

    DR. CORBETT: If this turns out to be a little superficial basal cell, there are superficially destructive methods that treat these very easily, and it should be no problem at all.

## Q Is there anything other than a superficial basal cell -- could it be something different than that?

    DR. CORBETT: Oh, it could be a little benign, inflammatory lesion or something. But the only way you know for sure is to biopsy these spots, and that's the reason you take tissue for biopsy.

## Q Have you been with the President in the past year?

    DR. CORBETT: Yes.

## Q So this was the first time it was discovered --

    DR. CORBETT: That's correct. He's had sun-damaged spots before, but this is the first time he's had a little spot that's been suspicious, actually, for a skin cancer.

## Q And what do you consider at this point the extent of his --

    DR. CORBETT: No, he's had previous cysts, but those are totally different. The little cysts are totally benign lesions and are very common, as well.

## Q How common is this in people of his age --

    DR. CORBETT: Basal cell skin cancer again is the most common type of skin cancer. Probably at least 800,000 to a million cases of basal cell in the United States every year. It's the locally growing type; it's not the type that spreads and goes other places. It just grows very slowly, locally.

## Q Dr. Mariano, could you describe the President's -- (inaudible) -- any overall recommendations given to him as he was leaving?

    DR. MARIANO: Well, you know, the President, he wants to always study for his exams, and passed them with flying colors. I think today he's been undergoing a lot of busy activity and travel, so he was I don't think in the top shape he wanted to be in. But medically, as a physician, he passed -- he had a fairly normal exam, except for the things we noted, such as the skin lesion and the elevated cholesterol. But those are things that are very easily managed on an out-patient basis.
    Also we gave him things to look at in the future for him to work on, such as diet, such as exercise. And I think he should do very well with that, with a new lifestyle for him.

## Q (Inaudible.)

    DR. MARIANO: Let me ask a cardiologist, Dr. Morrissey, he can discuss a little bit more about the medicine.
    DR. MORRISSEY: We'd like to emphasize, first of all, that throughout the entire time, Dr. Mariano has made sure that the President has been on a good diet program, as well as a regular aerobic exercise activity. So those are the fundamentals that we have to continue to stress, and the President plans on continuing to stress that therapy.
    But in the studying of his LDL, which was 134 on our last evaluation, today it was 177. As Dr. Mariano mentioned, that's the unhealthy cholesterol occurring on a patient that's very active and following a diet. It was time to initiate drug therapy. So we'll have him on one of the HMG -- inhibitors. We'll start a normal dose regiment, and we will do follow-up laboratory tests on him in approximately one month.

## Q (Inaudible.)

    DR. MARIANO: September 25, 1999. This is the 2000 exam and the departure exam.

## Q (Inaudible.)

    DR. MARIANO: There is a Department of the Navy instruction or an agreement since 1967-68 that authorizes former Presidents and First Ladies, or widows of former Presidents to receive Navy medical care. So the President is eligible to come here for his medical care and benefits, should he seek that. And he's aware of that.

## Q In 1990 -- (inaudible) -- he had a test for HIV. Did he have that again today?

    DR. MARIANO: No, he didn't. That test in 1990 for HIV was an insurance physical, and that was negative. But, no, he's not been offered that. He declined, he didn't feel it was indicated.

## Q Back in 1996, the President released a part of his medical records. Is there any plans of maybe releasing his full medical records?

    DR. MARIANO: No. In fact, no other President has released their entire records. What we have done in the last eight years is released summaries of our physical findings and then made those part of the record. So, in essence, that's in the records, the things we released.
    I know we've released biopsies of the sebaceous cyst in the past that he has had, we've done that as well. But having served President Bush in the final years of his presidency, I'm pretty certain in talking to all my predecessors that no one has released their records in entirety.

## Q Back to the cholesterol, what would have caused that? Was it demands, the stress of the presidency that helped increase the cholesterol level?

    DR. MARIANO: You know, the President is aware, he acknowledges that it's a combination of not the right type of diet, food that's on the road and long hours, and also not enough exercise. As you can recall, when he first came in as President, he used to run on a regular basis, and you don't seem him doing that anymore, he's not running as often as he wants to with the demands of his office. So, definitely, the demands of the office and the travel and all the things he does leave him very little time to focus on the exercise he wants to engage in.

## Q Doctor, the President said that his knee was fine. He told us that outside. I wonder, the kind of exercise that you'd like him to do more of, that would mean his knee is fine to do those kinds of workouts?

    DR. MARIANO: Right. The orthopedic surgeon and physical therapist essentially blessed him and considered that he's totally recovered from that surgery and he is free to do StairMaster, running. In fact, I think he started running early -- right after his surgery. And actually -- let me have Dr. Kellogg comment. He was with us to help with the rehab of the President and his knee. So, Dr. Bob Kellogg.
    DR. KELLOGG: The President's knee is looking just absolutely picture-perfect. He has been cleared really for the last two years to return to all activities that he's wanted to do. He has certainly expressed a strong interest to getting back out on the road and resuming his jogging plans. And there are really no limitations that he faces. He's been very active, working out regularly in the White House gym, but around the demands of his road schedule and that sort of thing.

## Q I want to ask a question about the cholesterol because the ratio of 5.1, what is exactly -- what does that mean? And the other item, you said that LDL is elevated from 134 to 177. I understand that, because that's the dangerous cholesterol. What about the 52 for triglycerides? Is that a normal --

    DR. MORRISSEY: Those are all good numbers that you're looking at. And you want to look at not only the total cholesterol, but all the subcomponents of cholesterol and also understanding what the triglyceride level is. So when the lab test was ordered today, it looked at all those various sub segments and that's what we like to look at.
    And the two things to focus in on here, knowing that the triglyceride level was normal, is looking at what his HDL cholesterol was and his LDL cholesterol. And the ratio kind of looks at what the HDL and the LDL look like. And the nice way to remember that is the HDL is high density lipoprotein and you want to get that as high as you can. And the way to bring up that HDL is pick your parents well, because genes are very effective for that. And then also good exercise and a moderate alcohol consumption sometimes can cause an elevation in the HDL.

## Q Is the HDL -- 52?

    DR. MORRISSEY: It was 46. His HDL was 46, which is a normal HDL. Now, if he had a low HDL, 35 or less, we would consider that an additional risk factor. But since the President's HDL is normal, we're happy with that. We do recommend, as we said, good diet and exercise, but we're also going to go after the LDL, the LDL being the poor cholesterol, and we're going to drive that down with diet, exercise and the medication. And our goal would be to bring that as far down as we can.

## Q Can I just mention one more thing about the cholesterol? Are there any brand-name drugs that we might understand better than the --

    DR. MORRISSEY: The medicine that we chose was Zocor simvastatin, the medication that is on the military formulary, and we use it for our active duty independents, and it's a very effective medicine. As I mentioned earlier, we will monitor liver function in a one-month time frame to make sure no adverse side effects.

## Q And one more thing. What sort of recommendations did you give the President as far as diet --

    DR. MORRISSEY: I know that recently, there's -- the Department of Agriculture put out a comparison of the different diets out there. We still go with the American Heart Association type diet and go with the low cholesterol, low fat diet. The President's chefs and the entire medical team has made sure that when possible, he gets a low-cholesterol, low-fat diet. So that's our goal in that.

## Q He isn't eating cupcakes by himself -- (laughter) -- what should he be eating?

    DR. MORRISSEY: There's been dietary instructions and, of course, we can supplement that to make sure there's enough education material provided to the new cooks for his meals.
    MR. SIEWERT: If you'd like to get him a steamer, Mark, that would be fine. Steam some vegetables. (Laughter.) Probably not the diet he had yesterday, in New Hampshire.
    I think that's it. Thank you all. Unless anyone had any pressing questions. Do you have one more?

## Q A question for Dr. Mariano. With the President leaving office in a week, from a personal and/or professional standpoint, do you care to describe how it has been to be the President's chief physician? (Laughter.)

    DR. MARIANO: You know, he is an amazing man. I have known him eight years and he's a good patient. He has a good heart, he's a good person, and it has been a privilege and an honor serving him. And I know that today, when he left here, he was very touched by seeing all the staff here at the hospital, because he really is impressed by military medicine. I didn't get to hear what he said about the hospital, but he is truly a great fan of military medicine and what they've done for his medical care and the dedication.
    Again, it has been a great honor serving him and serving at the White House. Thanks.
    MR. SIEWERT: That's a wrap. Thank you very much.
4:10 P.M. EST