A 21-year-old man had a one-minute generalized tonic-clonic seizure 15 minutes ago. He recently ran out of his levetiracetam two days ago. What is the most appropriate next step?

• A. Discharge home with Levetiracetam prescription
• B. Admit for IV benzodiazepine and observation
• C. Begin IV fluids and observe in ED
• D. Schedule outpatient EEG

Answer: (A)

Restarting his maintenance medication and sending him home is the right move when a patient with known epilepsy experiences a single completed seizure that was precipitated by stopping therapy. He’s already recovered from the episode, there are no focal neurological deficits, and there’s a clear, identifiable trigger (nonadherence to levetiracetam). In this situation, the immediate goal is to prevent another seizure by promptly resuming his antiseizure medication, rather than admitting for aggressive in-hospital testing or treatment.

Admitting for IV benzodiazepines and observation is reserved for ongoing seizure activity or status epilepticus, which isn’t present once he’s back to baseline. Beginning IV fluids and observing in the ED isn’t needed if he’s stable and fully recovered. An outpatient EEG isn’t urgent in the setting of a clearly precipitated breakthrough seizure due to nonadherence; it can be considered later if there’s diagnostic uncertainty or recurrent seizures. So, the best step is to restart levetiracetam and arrange follow-up to ensure adherence and monitor response.