Seizure Disorders USMLE Step 1 Practice Question
A 42-year-old woman with a 3-year history of focal onset seizures with impaired awareness presents for follow-up evaluation. She reports 2-3 breakthrough seizures per month despite strict adherence to levetiracetam monotherapy at 3000 mg daily. Recent serum levetiracetam level is 28 mcg/mL (therapeutic range 12-46 mcg/mL). Vital signs are stable, and general neurologic examination is unremarkable. Brain MRI with and without gadolinium obtained 2 months ago showed no acute abnormalities, prior infarction, or focal lesions. Pregnancy test is negative. She denies medication side effects, recent illness, or medication non-adherence. Which of the following is the most appropriate next step in management?
Answer choices
- AIncrease levetiracetam to maximum tolerated dose (5000 mg daily)
- BAdd a second-line antiepileptic drug with a different mechanism of actionCorrect answer
- CSwitch to phenytoin monotherapy due to superior efficacy in focal seizures
- DObtain repeat brain MRI with focus on high-resolution temporal lobe imaging
- ERefer for vagal nerve stimulation as she meets criteria for drug-resistant epilepsy
- FRefer for epilepsy surgery evaluation and intraoperative electrocorticography
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