At wards 101 we discussed a case of a 44 year old male who underwent alcohol withdrawal (estimated 30 cans of beer per day) at an outside hospital of 3 days duration and then was brought back to the hospital for continued altered mental status and a fall. Prior history included seizures with alcohol withdrawal although no witnessed seizures per records. On arrival to the hospital he had an AKI up to 5.2 (BUN 81, prior was normal) and head CT was concerning for small subdural hematoma. CK was elevated at 7000 and EEG showed REM rebound which can be caused by withdrawal from sedating medications or as a complication after seizures.
Remember that patients with history of significant alcohol use can have prolonged withdrawal. Also remember that not all seizure activity will be visible to the naked eye so in a patient with history of seizures and encephalopathy, CK and EEG are going to be important diagnostic tools.