Background. In different literature sources paraesophageal hernias (PEH) comprises from 5% to 10% of all hiatal hernias (HH). Symptoms are wide ranging and patients with PEHs are often labeled as asymptomatic or minimally symptomatic. Higher mortality rates are related to type III or IV hernias in elder patients with concomitant diseases. Thereby diagnostic of PEH can be challenging with high risk of reduced quality of life and fatal complications due to late onset diagnosis. Case report. A 69 years old woman was diagnosed with schizophrenia in 2006 and in the past years has not taken any prescribed medication. Due to lack of eating and talking for 2 weeks, on 5th December 2019 she was hospitalized with primary diagnose - acute cerebral ischemia. A head CT scan revealed only bilateral mastoiditis. Chest x-ray showed type IV PEH. On 6th December 2019 chest CT scan showed wide retrocardiac HH with gastric inflammation in hernial sac and compromised right lower pulmonal lobe. After a thorough evaluation and physical examination, indications for acute operative treatment were not found. Patient was stabilized and started to eat and drink, although refused to take any further diagnostic tests. After repeated consultations with different specialists, a decision was made to compensate psychiatric condition followed by elective surgical PEH treatment. Diagnostics of PEH was delayed due to complicated background of concomitant diseases. Conclusion. Not all PEHs presents symptomatic. Asymptomatic type IV PEH diagnostics may be challenging. This case report presents rarely common type IV PEH in patient with concomitant diseases which demands multidisciplinary approach. The major issue in clinical decision-making in PEH concerns the assessment of symptoms, where late onset diagnosis may lead to reduced quality of life and fatal complications.