University of Minnesota Medical Center, Fairview PHYSICIAN PROGRESS NOTES

Patient Identification Plate

aGVHD Assessment –PEDIATRIC in Past 7 Days from __________ to ____________

CHECK ONE : No Acute GVHD to Date

History of Acute GVHD with no current Flare Acute GVHD progressed to Chronic (Complete Chronic GVHD Forms-baseline)

Active Acute GVHD (complete Clinical GVHD Assessment below)

Clinical GVHD Assessment – Highest Stage in Past 7 Days from __________to _____________

Lansky Score____________

Organ: CLINICAL Stage: Biopsy: (circle GVHD involved organ) (if done in past 7 days) 0 1 2 3 4 + - Equ Skin % rash: ______ [<25%] [26-50] [>50%] [bullous / Desquamation]

Lower GI vol: __________/m² <280ml/m² ( 281- ( 556- (>834ml) [severe abd pain w/ or w/o 555ml/m²) 833ml/m²) frank blood or ileus

Liver max bili: ________ ____________________ [2.1 - [3.1 - [6.1 - [>15.1] 3.] 6] 15) Upper GI ____________________ [Persistent nausea / vomiting / anorexia] -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Current Treatment of acute GVHD CSA prophy MMF Pred/MPred TCM/HCT ATG Sirolimus

MPred Boluses Tacrolimus Study Drug ________________ Other____________________

Signature____________________________________________

PEDS LOWER GI HT________ 0 ( <280ml/m² ) WT________

1 ( 281-555ml/m² ) BSA_______m² 2 ( 556-833ml/m² ) 3 ( >834ml/m² )

4/3//2008

Differential Diagnosis: (MUST complete if other organ etiology occurring) Drug Infect TPN VOD Other _____________________

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A t GVHD A t FAcute GVHD Assessment Form

CLINICAL ACUTE GVHD ASSESSMENT

DATE: DAY+ WEEK OF ASSESSMENT: KPS/LPS: Code Differential Diagnosis Drug Cond

0 0(GI) 1 2 3 4 GVHD Rxn Reg TPN Infect VOD Other 0 0(GI) 1 2 3 4 GVHD Rxn Reg TPN Infect VOD OtherSkin � � � � � % body rash: ___ � � � � Lower GI � � � � � � vol: ____ � � � � � Upper GI � � � � � � � Liver � � � � � max bill: � � � � � �Liver � � � � � max bill: _________ � � � � � �Code Definitions:

Skin: Lower GI (Diarrhea): Upper GI: Liver (Total Bilirubin):0 No rash 0 No diarrhea 0 No persistent 0 < 34 umol/L 1 Maculopapular rash, 0(GI) Diarrhea < 500 mL/day or < 280 mL/m2/day nausea or vomiting 1 34-52 umol/L

<25% of body surface 1 Diarrhea > 500 but < 1000 mL /day or 280 555 mL/m2/day 1 Persistent nausea 2 53 103 umol/L <25% of body surface 1 Diarrhea > 500 but < 1000 mL /day or 280-555 mL/m /day 1 Persistent nausea, 2 53-103 umol/L2 Maculopapular rash, 2 Diarrhea > 1000 but < 1500 mL/day or 556-833 mL/m2/day or vomiting 3 104-256 umol/L 25-50% of body surface 3 Diarrhea > 1500 mL/day or > 833 mL/m2/day 4 > 256 umol/L 3 Generalized erythroderma 4 Severe abdominal pain, with or without ileus 4 Generalized erythroderma (use mL/day for adult recipients and mL/m2/day for pediatric recipients) with bullous formation and

desquamation desquamation Physician Signature

DMF001.00 December, 2008