(Attach Label here or Complete Details)
NAME:___________________________________________________ NHI:__________
GENDER: ____
HSCT Programme
Haematology
DOB:______________
AGE:______
WARD:________________
Day 100 Assessment Post-HSCT
This assessment needs to reflect the last 100 days post transplant. Please report the highest grades
TRANSPLANT DETAILS
Date of Transplant:
Date of Admission :
FBC on discharge:
ABO incompatibility:
GVHD prophylaxis:
VOD prophylaxis:
Conditioning Regime:
Date of Discharge:
Performance Status:
Cell Sources:
TNC Dose:
CD34+ Dose:
FUNCTIONAL STATUS AT DAY 100
Occupation:
Karnovsky Scale:
Full-time
Part-time
Not Working
DISEASE STATUS
Complete Remission
Partial Remission
Stable Disease
Relapse
Date established:
Evidence:
Clinical
Histological
Radiological
Minimal residual disease test
COUNT RECOVERY
Record first 3 consecutive days
9
Neutrophils ≥ 0.5 x 10 /L
9
Neutrophils ≥ 1.0 x 10 /L
Record how many days post-HSCT
Date:
Date:
Day +
Day +
Record first 3 consecutive days without transfusion in previous 7 days
9
Platelet ≥ 20 x 10 /L
9
Platelet ≥ 50 x 10 /L
Date:
Date:
Record how many days post-HSCT
Day +
Day +
POST-TRANSPLANT DETAILS
Date of last red cell transfusion:
Date of last platelet transfusion:
CMV Status:
Engraftment Syndrome?
Did any GVHD occur?
No
No
Yes
Yes
Date & Symptoms:
Acute
Chronic
cGVHD is rare before day 100, if this occurs complete the 6 month and annual assessment post-HSCT form
Clinical Significant Infections:
(include organisms)
Antibiotics:
Significant Organ Impairment:
(include investigations)
Current Medications:
Additional Issues/Advice:
Acute GVHD
Date of Onset:
Histological Evidence:
YES
NO
Is acute GVHD still present at date of contact?
YES
Clinical Evidence:
YES
NO
NO
Progressed to chronic
List maximum severity of organ involvement
Skin
Treatment therapy used:
Start & Stop Dates:
No symptoms/rash not attributable to GVHD
Stage 1 Maculopapular rash < 25% BSA
Stage 2 Maculopapular rash 25 – 50% BSA
Stage 3 Generalised erythroderma
Stage 4 Generalised erythroderma with bullae formation and desquamation
Ref:5004
Authorised By: Programme Director
Page 1 of 2
Version: 1
Issue Date: January 2014
(Attach Label here or Complete Details)
NAME:___________________________________________________ NHI:__________
GENDER: ____
DOB:______________
AGE:______
WARD:________________
Day 100 Assessment
Post-HSCT
Treatment therapy used:
Gut (lower intestinal tract)
Start & Stop Dates:
Symptoms not attributable to GVHD
Stage 0 No diarrhoea
Stage 1 Abdominal pain without significant weight loss (<5%). Diarrhoea ≥ 500ml/day but ≤ 1000ml/ day
Stage 2 Mild to moderate weight loss (5-15%) Diarrhoea > 1000ml.day but ≤ 1500ml/day
Stage 3 Significant weight loss > 15% Diarrhoea > 1500ml/day
Stage 4 Severe abdominal pain with or without ileus
Treatment therapy used:
Upper Intestinal Tract
Stage 0 No persistent nausea or vomiting
Stage 1 Persistent nausea or vomiting
Start & Stop Dates:
Treatment therapy used:
Liver
No liver acute GVHD / bilirubin level not attributable to acute GVHD
Start & Stop Dates:
Stage 0 Bilirubin < 2.0 mg/dL (< 34 µmol/L)
Stage 1 Bilirubin 2.0 – 3.0 mg/dL (34 – 52 µmol/L)
Stage 2 Bilirubin 3.1 – 6.0 mg/dL (53 – 103 µmol/L)
Stage 3 Bilirubin 6.1 – 15.0 mg/dL (104 – 256 µmol/L)
Stage 4 Bilirubin > 15.0 mg/dL (> 256 µmol/L)
Other Organ Involvement:
No
Yes
Organ Involved:
Date of Onset:
Maximum overall grade (Glucksberg):
Grade I (mild) skin stage 1 or 2 only (no liver or gut aGVHD)
Grade II (moderate) up to stage 1 liver or gut, up to stage 3 skin
Grade III (severe) up to stage 4 liver, up to stage 3 in any other organ
Grade IV (life threatening) stage 4 skin or gut, ECOG/WHO performance status 4 or Karnofsky performance
score < 30%
Physician Performing Assessment
Name:
Signed:
Date:
Place form in patients medical record AND email a copy to the BMT Coordinator or fax (03) 364 1486
References: www.bloodref.com
Ref:5004
Authorised By: Programme Director
Page 2 of 2
Version: 1
Issue Date: January 2014