A 41-year-old man presented to the emergency department with a 9-month history of cough, exertional dyspnea, nocturnal diaphoresis, and weight loss of 10 kg. The physical examination revealed painless, massive, discrete, rubbery cervical, supraclavicular and axillary lymphadenopathy. Plain radiography of the chest showed bilateral hilar lymphadenopathy. The serum calcium level was elevated at 16.2 mg per deciliter; serum parathyroid hormone is within normal range. A diagnostic investigation was performed on him

**Core Concept**
The patient's presentation, including lymphadenopathy, elevated serum calcium, and normal parathyroid hormone levels, suggests a diagnosis of a paraneoplastic syndrome associated with a malignancy that secretes parathyroid hormone-related protein (PTHrP).

**Why the Correct Answer is Right**
The elevated serum calcium level in this patient is due to the production of PTHrP by a malignancy, which mimics the action of parathyroid hormone (PTH) on the bones, kidneys, and intestines, leading to hypercalcemia. This is a classic paraneoplastic syndrome, where a tumor produces a substance that has systemic effects. In this case, the tumor is likely to be a squamous cell carcinoma of the lung, which is known to produce PTHrP.

**Why Each Wrong Option is Incorrect**
**Option A:** This option is incorrect because it does not address the paraneoplastic nature of the patient's hypercalcemia. While hyperparathyroidism can cause elevated serum calcium levels, the normal parathyroid hormone levels in this patient make this option incorrect.

**Option B:** This option is incorrect because it does not account for the lymphadenopathy and bilateral hilar lymphadenopathy seen in this patient. These findings suggest a malignancy, but the option does not address the paraneoplastic syndrome associated with PTHrP production.

**Option C:** This option is incorrect because it does not provide a clear diagnosis or explanation for the patient's presentation. While it mentions a "malignancy," it does not specify the type of malignancy or the paraneoplastic syndrome associated with it.

**Option D:** This option is incorrect because it is too vague and does not provide a clear diagnosis or explanation for the patient's presentation. It mentions a "tumor" but does not specify the type of tumor or the paraneoplastic syndrome associated with it.

**Clinical Pearl / High-Yield Fact**
When encountering a patient with hypercalcemia and normal parathyroid hormone levels, consider the possibility of a paraneoplastic syndrome associated with PTHrP production. Squamous cell carcinoma of the lung is a common malignancy that can produce PTHrP, leading to hypercalcemia.

**Correct Answer:** C. Chest radiography and CT scan of the thorax revealed a 4 cm squamous cell carcinoma of the lung with bilateral hilar lymphadenopathy.

✓ Correct Answer: B. Excisional biopsy of the axillary node