Spontaneous rectus sheath hematoma (SRSH) is an uncommon medical emergency in the elderly. We present a case of SRSH with an atypical clinical presentation and discuss literature regarding diagnosis and proper management. A 75-year-old female patient was transferred to the emergency department due to acute dyspnoea and confusion. Her medical history revealed a viral infection of the upper respiratory tract, and no coughing or use of anticoagulants. The clinical examination showed tenderness of the left lower abdomen, although palpation was misleading due to patient’s obesity. Laboratory investigations showed light anaemia. Ultrasonography and computed tomography revealed a large rectus sheath hematoma of the left abdominal wall. Despite further deterioration of the patient, conservative management including bed rest, fluid replacement, blood products transfusion, and proper analgesia was successful. No surgical intervention was needed. Prompt diagnosis and management of SRSH plays significant role in the prognosis, especially in elder patients. Independently of size and severity, conservative management remains the first therapeutic choice. Only by failure of supportive management, progressive and large hematoma or uncontrollable hemodynamic patients, interventional management including surgery or less invasive newer techniques is indicated. 1. Introduction Spontaneous rectus sheath hematoma (SRSH) is an uncommon entity [1]. The aging population and increased use of anticoagulant therapy without adequate control of coagulation parameters have caused a significant rise in the incidence of this condition in the last decades [2, 3]. SRSH is usually self-limiting but can evolve to a life-threatening emergency, especially for the elderly [2, 4]. This is mainly due to the low health status and various comorbidities that are observed in this group of patients, whereas delayed diagnosis plays a significant role as well. We present a case of an elder patient with SRSH and an unusual clinical presentation. We highlight the importance of prompt diagnosis and management of this medical emergency and include a review of the literature. 2. Case Report A 75-year-old woman was transferred to our emergency department due to sudden onset of dyspnoea and confusion. She reported nasal congestion, sneezing, and malaise during the last three days, indicating a possible viral infection. The patient reported no significant comorbidities except from arterial hypertension under therapy, no coughing, and no anticoagulant use. On examination, her temperature was 37.0°C, blood
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