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First unprovoked seizure — MCCQE Part 1 MCQ

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ModerateSeizuresFirst unprovoked seizureMCCQE Part 1

34-year-old man presents with a witnessed generalized tonic-clonic seizure. He is now alert, glucose and sodium are normal and there is no infection. Which of the following is the most appropriate next step?

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Correct answer: B — Arrange brain imaging, EEG and driving counselling with neurology follow-up

Arrange brain imaging, EEG and driving counselling with neurology follow-up is best because a first unprovoked seizure requires evaluation for structural and epileptiform causes and safety counselling. Discharge with reassurance and routine follow-up only is suboptimal because it underestimates acute or progressive risk; Treat symptomatically and defer definitive assessment is suboptimal because symptom control alone does not address the likely underlying diagnosis; Arrange non-urgent outpatient imaging in several months is suboptimal because delayed imaging is unsafe when the presentation has red flags; Start long-term corticosteroids without confirming the diagnosis is suboptimal because empiric steroids can obscure infection, malignancy or other diagnoses. Driving restrictions are a key Canadian medico-legal counselling point.

Reference: Canadian League Against Epilepsy guidance