Alcohol withdrawal Quiz: Ace Your Exams

A 68-year-old woman presents to the emergency department for evaluation of alcohol withdrawal. The patient reports last using alcohol approximately 20 hours ago. She has been drinking one to two bottles of wine per day for ten years since her partner’s death. She has a history of being treated for multiple episodes of alcohol withdrawal but has no history of alcohol withdrawal seizures. She has a history of acute pancreatitis five years ago secondary to alcohol use. She has no visual or tactile disturbances, anxiety, agitation, nausea, or vomiting. She occasionally uses marijuana and tobacco. Temperature is 37°C (98.6°F), blood pressure is 140/60 mmHg, pulse is 88/min, respiratory rate is 18/min, oxygen saturation is 100% on room air. She is alert and at her baseline mental status. She is not diaphoretic. She has evidence of a mild tremor in both hands with outstretched arms and fingers spread but is otherwise well-appearing. Which of the following factors indicates that this patient is at risk for severe alcohol withdrawal with potential complications?