The only topic on anyone’s mind in recent months has been the health of Senate President Dominick Ruggerio, and he didn’t make a great first impression Tuesday afternoon. The 76-year-old has been battling cancer, and it has clearly taken its toll on him. He’s lost weight. He’s moving more slowly. And he missed most of the session last year. But he easily won reelection in Senate District 4 last fall, and then beat back a challenge for the presidency from Senator Ryan Pearson, his former majority leader.

Now he’s locked in for another two-year term leading the Senate, but the open question among his colleagues – and anyone paying any attention to Rhode Island politics – is whether he’s up for the job.

From the front row: My colleague Ed Fitzpatrick was in the chamber Tuesday for opening day, so I asked him to explain what happened.

Ed writes: “After battling cancer and shingles over the last year, Senate President Ruggerio’s No. 1 priority had to be showing that he was back in charge and capable of presiding over the chamber. But in the roll call for Senate president, he paused and then voted ‘present’ rather than voting for himself. At first, his vote drew laughs. And if he meant it as a joke, it would have been seen as a bad-ass response to the rebels who also voted ‘present,’ in effect abstaining.”

But after the session, a tired-looking Ruggerio told reporters he hadn’t heard the question and meant to vote for himself. Ruggerio had no opponent in Tuesday’s vote, so in a way his vote wasn’t an issue. But his confusion over the vote for his own leadership had the State House buzzing, showing that Ruggerio’s health remains a major issue in the Senate.

The opening day of the legislative session is often tightly scripted. But the Senate session seemed off from the get-go, when Ruggerio was sworn in and placed his hand on a Bible app on Senate Minority Leader Jessica de la Cruz’s cell phone because no one remembered to bring a Bible.

The bigger picture: It’s easy to compare Ruggerio’s poor health to President Joe Biden, who ended his reelection campaign last year following a disastrous debate performance against Donald Trump. But being president of the Rhode Island senate doesn’t come with the nuclear codes, and the state government will be fully functional whether Ruggerio is present or not.

Still, within the chamber, the concern is real.

He won the presidency with 26 out of 38 votes, which was comfortable but not overwhelming the way it has been in previous years. That puts a tremendous amount of pressure on Ruggerio’s staff and leadership newbies like Majority Leader Val Lawson and Whip David Tikoian to hold down the fort.

The Senate only plans to meet once a week as a full body, so it’s possible that Ruggerio’s committee chairs will hold high-profile hearings – think Oversight, for example – that could serve to shield the president for a while. But there will come a time in the coming months where Ruggerio is going to have to prove to the people who just voted for him again as president that he is fit to lead the chamber.

This story first appeared in Rhode Map, our free newsletter about Rhode Island that also contains information about local events, links to interesting stories, and more. If you’d like to receive it via e-mail Monday through Friday, you can sign up here.

Dan McGowan can be reached at dan.mcgowan@globe.com. Follow him @danmcgowan.