<s>[INST] Please i need help i am a 37 year old female a smoker,, i have copd in my lungs.but my question is i have been coughing and spitting up blood i have the worst pain in the middle part of my back into my shoulders..can a dr please tell me whats going on [/INST] This symptom is serious and requires immediate medical evaluation. There are many causes of coughing up blood and you need further testing. This would start with a chest x-ray and likely a CT of the chest and possibly bronchoscopy. </s>