In this case, lung cancer is far and away the leading diagnosis. Perhaps, lymphoma and other metastatic cancer could be considered. Less likely considerations would include fungal disease, and sarcoid.
Focal wheeze: Endobronchial cancer resulting in airway narrowing.
Hoarseness: Recurrent Laryngeal Nerve involvement with AP window lymphadenopathy.
Cough and/or Hemoptysis: Suggests endobronchial pathology raising the likelihood that bronchoscopy will visualize the suspected lesion and yield a diagnosis.
Myosis, Anhydrosis, and Lid Lag: Suggests a Pancoast tumor.
Hyponatremia: Suggests SIADH which is most common with small cell carcinoma.
Hypercalcemia: Suggests squamous cell carcinoma in which hypercalcemia may result from direct bone involvement or the production of a parathyroid-like hormone.
Fine needle aspiration of the supra-clavicular lymph node. While bronchoscopy would have a high yield for identifying the primary endobronchial lesion, FNA of the supraclavicular lymph node could not only establish the diagnosis of malignance but would also stage the patient as well. If positive, the patient would be staged as N3 disease and as such would not be a candidate for surgery and no further invasive procedures would be indicated.
Stage 3b, T2N3M0. Prognosis would obviously be poor with 5 year survival estimated at between 3 and 7 %.