Center, San Jose, CA (Tracking ID #75786) LEARNING OBJECTIVES: To diagnose nephrotic syndrome in a diabetic. To assess the clinical complications of nephrotic syndrome. To recognize the clinical challenges of the obese patient. CASE INFORMATION: A 52 year old morbidly obese male presented to his primary care physician with four days of facial and upper extremity edema. He had developed orthopnea, paroxysmal nocturnal dyspnea, and dyspnea with exertion. His past medical history included poorly controlled diabetes, chronic lower extremity edema, and untreated obstructive sleep apnea. An initial chest CT demonstrated pleural effusions and a soft tissue mediastinal mass thought to be compressing the superior vena cava. Mediastinoscopy of the mass demonstrated no tissue findings; a repeat chest CT, with dye injected in both arms simultaneously, revealed the mass was likely lipomatosis. Further workup of the pleural effusion included an unremarkable echocardiogram and an ultrasound-guided thoracentesis. The pleural effusion was transudative and negative for cytology. The patient's urine revealed 3+ proteinuria and oval fat bodies, and a spot urine protein/creatinine ratio demonstrated over 4 grams of protein.