LTM Secure Access جهت دسترسی به فرم گزارش، رمز عبور را وارد کنید. رمز عبور وارد شده اشتباه است. ورود به سیستم LTM Pro 7.5 ACNS & ILAE Compliant 💾 Save Data 📂 Load Data 🖨️ Print Report Long-Term Monitoring (LTM) Report Department of Neurology | Dr. M. T. Farzadfard Long-Term Monitoring (LTM) Report Department of Neurology – Comprehensive Epilepsy Center Dr. M. T. Farzadfard | Neurologist / Fellowship of Epilepsy 1. Patient Information Full Name Patient ID National ID Age GenderMaleFemale HandednessRightLeftAmbidextrous EducationSelect...IlliterateHigh SchoolBachelorMaster/PhD Phone 1 Phone 2 Admission Date Discharge Date 2. Social History & Habits Occupation Marital StatusSingleMarriedDivorced Residence SmokingNoYes (Smoker)Ex-Smoker AlcoholNoneSocialHeavy Drugs/OpiumNoneOpiumCannabisOther Notes 3. Risk Factors Fever-induced Seizures CNS Infection Head Trauma (Mod/Sev) Perinatal Complications Neurodevelopmental Disorder Family Hx Epilepsy Family Hx Neuro Parental Consanguinity 4. Clinical Seizure History Frequency Age of Onset Last Seizure Acute Repetitive/StatusNoYes Triggers Aura Postictal Seizure Types (ILAE 2017) Focal Aware Focal Impaired Awareness Focal to Bilateral TC Focal Motor Focal Non-Motor Generalized TC Absence Myoclonic Tonic Atonic Epileptic Spasms Semiology Description 5. Medication History (ASM) Current ASMs (Anti-Seizure Medications) Acetazolamide Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Brivaracetam Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Cannabidiol (CBD) Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Carbamazepine Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Cenobamate Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Clobazam Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Clonazepam Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Diazepam Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Divalproex sodium Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Eslicarbazepine acetate Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Ethosuximide Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Felbamate Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Fenfluramine Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Fosphenytoin Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Gabapentin Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Ganaxolone Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Lacosamide Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Lamotrigine Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Levetiracetam Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Lorazepam Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Midazolam Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Nitrazepam Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Oxcarbazepine Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Perampanel Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Phenobarbital Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Phenytoin Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Primidone Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Rufinamide Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Sodium valproate (Valproic acid) Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Stiripentol Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Tiagabine Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Topiramate Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Vigabatrin Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Zonisamide Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) None Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Other (Specify) Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Past / Failed ASMs Acetazolamide Dose: Freq: Select... QD BID TID QID QHS PRN Brivaracetam Dose: Freq: Select... QD BID TID QID QHS PRN Cannabidiol (CBD) Dose: Freq: Select... QD BID TID QID QHS PRN Carbamazepine Dose: Freq: Select... QD BID TID QID QHS PRN Cenobamate Dose: Freq: Select... QD BID TID QID QHS PRN Clobazam Dose: Freq: Select... QD BID TID QID QHS PRN Clonazepam Dose: Freq: Select... QD BID TID QID QHS PRN Diazepam Dose: Freq: Select... QD BID TID QID QHS PRN Divalproex sodium Dose: Freq: Select... QD BID TID QID QHS PRN Eslicarbazepine acetate Dose: Freq: Select... QD BID TID QID QHS PRN Ethosuximide Dose: Freq: Select... QD BID TID QID QHS PRN Felbamate Dose: Freq: Select... QD BID TID QID QHS PRN Fenfluramine Dose: Freq: Select... QD BID TID QID QHS PRN Fosphenytoin Dose: Freq: Select... QD BID TID QID QHS PRN Gabapentin Dose: Freq: Select... QD BID TID QID QHS PRN Ganaxolone Dose: Freq: Select... QD BID TID QID QHS PRN Lacosamide Dose: Freq: Select... QD BID TID QID QHS PRN Lamotrigine Dose: Freq: Select... QD BID TID QID QHS PRN Levetiracetam Dose: Freq: Select... QD BID TID QID QHS PRN Lorazepam Dose: Freq: Select... QD BID TID QID QHS PRN Midazolam Dose: Freq: Select... QD BID TID QID QHS PRN Nitrazepam Dose: Freq: Select... QD BID TID QID QHS PRN Oxcarbazepine Dose: Freq: Select... QD BID TID QID QHS PRN Perampanel Dose: Freq: Select... QD BID TID QID QHS PRN Phenobarbital Dose: Freq: Select... QD BID TID QID QHS PRN Phenytoin Dose: Freq: Select... QD BID TID QID QHS PRN Primidone Dose: Freq: Select... QD BID TID QID QHS PRN Rufinamide Dose: Freq: Select... QD BID TID QID QHS PRN Sodium valproate (Valproic acid) Dose: Freq: Select... QD BID TID QID QHS PRN Stiripentol Dose: Freq: Select... QD BID TID QID QHS PRN Tiagabine Dose: Freq: Select... QD BID TID QID QHS PRN Topiramate Dose: Freq: Select... QD BID TID QID QHS PRN Vigabatrin Dose: Freq: Select... QD BID TID QID QHS PRN Zonisamide Dose: Freq: Select... QD BID TID QID QHS PRN None Dose: Freq: Select... QD BID TID QID QHS PRN Other (Specify) Dose: Freq: Select... QD BID TID QID QHS PRN Drug Allergy / Adverse Reactions Acetazolamide Brivaracetam Cannabidiol (CBD) Carbamazepine Cenobamate Clobazam Clonazepam Diazepam Divalproex sodium Eslicarbazepine acetate Ethosuximide Felbamate Fenfluramine Fosphenytoin Gabapentin Ganaxolone Lacosamide Lamotrigine Levetiracetam Lorazepam Midazolam Nitrazepam Oxcarbazepine Perampanel Phenobarbital Phenytoin Primidone Rufinamide Sodium valproate (Valproic acid) Stiripentol Tiagabine Topiramate Vigabatrin Zonisamide None Other (Specify) 6. Physical Examination Mental StatusNormalConfusedLow IQ/ID Cranial NervesNormalAbnormal Motor SystemNormalHemiparesis (L)Hemiparesis (R)Gen. Weakness Sensory SystemNormalAbnormal CerebellarNormalAtaxiaTremor GaitNormalAtaxicHemiparetic 7. Paraclinics Lab Results NormalHyponatremiaAbnormal LFTOther ASM Drug Levels TherapeuticSub-therapeuticToxicNot Done Neuroimaging (MRI) Normal MTS Right MTS Left FCD (Cortical Dysplasia) Tumor/Mass Cavernoma Gliosis/Encephalomalacia Generalized Atrophy Not Done Other (specify) 8. LTM Findings (ACNS Compliant) Interictal Background Normal PDR Diffuse Background Slowing Focal Slowing Asymmetry IEDs (Interictal Epileptiform Discharges) Sleep Architecture Normal Architecture Recorded Abnormal/Missing Architecure Not Recorded Activation Procedures (HV & Photic) Other EEG Findings / Additional Notes Recorded Seizures / Clinical Events + Add Event # Date / Time Semiology EEG Onset / Pattern Classification Duration Del No clinical events or seizures were recorded during this Long-Term Monitoring admission. 9. Conclusion & Plan A. Epilepsy Classification (ILAE 2017) Focal Onset Epilepsy Generalized Onset Epilepsy Combined Generalized & Focal Unknown Onset Epilepsy PNES B. Epileptogenic Zone Right mesial temporal lobe Left mesial temporal lobe Right hippocampus Left hippocampus Right amygdala Left amygdala Right temporal neocortex Left temporal neocortex Right temporal pole Left temporal pole Right frontal lobe Left frontal lobe Right orbitofrontal cortex Left orbitofrontal cortex Right dorsolateral prefrontal cortex Left dorsolateral prefrontal cortex Right supplementary motor area (SMA) Left supplementary motor area (SMA) Right anterior cingulate cortex Left anterior cingulate cortex Right parietal lobe Left parietal lobe Right postcentral gyrus Left postcentral gyrus Right supramarginal gyrus Left supramarginal gyrus Right occipital lobe Left occipital lobe Right primary visual cortex Left primary visual cortex Right insular cortex Left insular cortex Right perisylvian cortex Left perisylvian cortex Bilateral temporal lobes Unknown / not localized C. Etiology (ILAE) Select etiology... Structural Genetic Infectious Metabolic Immune Unknown Summary & Conclusion ✨ Auto-Write Plan & Recommendations ✨ Suggest Plan Discharge Medications (ASM Plan) Acetazolamide Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Brivaracetam Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Cannabidiol (CBD) Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Carbamazepine Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Cenobamate Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Clobazam Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Clonazepam Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Diazepam Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Divalproex sodium Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Eslicarbazepine acetate Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Ethosuximide Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Felbamate Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Fenfluramine Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Fosphenytoin Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Gabapentin Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Ganaxolone Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Lacosamide Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Lamotrigine Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Levetiracetam Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Lorazepam Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Midazolam Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Nitrazepam Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Oxcarbazepine Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Perampanel Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Phenobarbital Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Phenytoin Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Primidone Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Rufinamide Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Sodium valproate (Valproic acid) Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Stiripentol Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Tiagabine Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Topiramate Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Vigabatrin Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Zonisamide Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) None Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) Other (Specify) Dose: Freq: Select... QD (Once daily) BID (Twice daily) TID (Three times) QID (Four times) QHS (Nightly) PRN (As needed) + Add Non-standard Med Dosage Instructions & Tapering Plan Neurology Fellow / Resident Dr. M. T. Farzadfard Neurologist / Fellowship of Epilepsy Neurology Fellow / Resident Dr. M. T. Farzadfard Neurologist / Fellowship of Epilepsy
