Students encounter three simulated patients in the hospital presenting with the same symptom. On each patient, they take a focused history, perform a physical exam, and review diagnostic tests. Students huddle to obtain a shared mental model, then begin a treatment plan. Post simulation debriefing enhances reflection and metacognition.

1. Morning Rounds
A High Fidelity Mannequin Based Simulation for Second Year
Medical Students

2. Welcome
Objectives
The participant will be able to:
● Understand the design and
implementation of a morning rounds
simulation.
● Understand how the simulation activity
enhances students’ clinical reasoning skills
related to determining differential
diagnosis.

3. Prebrief Discussion
Expectations
Roles
Confidentiality
Fiction Contract
Safety Phrase
Basic Assumption

4. Brief history of present illness
Focused physical assessment
Order labs, test
Expectations

5. Team leader - HPI
Physical exam
Patient monitor set up and watch closely
Roles

6. HIPAA rules apply
Safe environment to make mistakes
No discussion of the scenario or participant performance outside
of the simulation activity
Confidentiality

7. It is understood that the mannequin is plastic and does not look or
feel like a live patient
The scenario is made to be as real as possible
Technology is not perfect; we do the best we can to fix problems
quickly
Participants should act as if the mannequin is a real patient
We are not trying to trick or deceive
Fiction Contract

8. Let people know if there is a problem that is not part of the
simulation activity and there is a need for immediate help
“This is not a simulation”
Safety Phrase

9. Everyone present is ready to participate with their best effort, and
they care about their patients and care provided.
Basic Assumption

10. Patient #1
CC: “I have had difficulty catching my breath
for the past 2-3 days”
HPI:
● Cough
● Yellow phlegm
● PMI: COPD
Initial PE:
● Lips cyanotic
● Sinus rhythm - no murmurs, rubs, or
gallop
● Lungs - Wheezing
HR: 100
BP: 146/100
SpO2: 88%
T: 99°
RR: 26
Other Cues:
● WBC 12,500
● Respiratory acidosis
● CXR - hyperinflation w/o opacities

11. Patient #1 Handoff Situation
What is going on
with the patient?
The patient is a 64 year old who has presented to the ER this
morning with severe shortness of breath that began 3 days ago.
They state: “I have had difficulty catching my breath for the past
2 – 3 days.
Background
What is the clinical
background or
context?
The patient denies chest pain, fever, chills, or lower extremity
edema. They have noted difficulty catching their breath with
minimal exercise at first and at rest now.
Vital signs are:
Heart rate = 100
Blood Pressure = 146/100
Temperature = 99.0 °F
O2 sat on room air = 88%
Respiratory rate = 26
Assessment
What do I think the
problem is?
I’m not sure what is going on with the patient, so I called you.
Recommendation
What would I do to
correct it?
We need your team to see the patient now.

12. Patient #2
“I’ve been out of breath since I woke up this
morning”
HPI:
● Frothy phlegm
● PMI: Asthma
Initial PE:
● Lips cyanotic
● Sinus rhythm - Systolic murmur, no rubs
or gallops
● Lungs - Crackles
HR: 95
BP: 190/130
SpO2: 90%
T: 99°
RR: 30
JVP > 4
Other Cues:
● BNP = 1080
● Respiratory acidosis
● CXR - Pulmonary edema with left
ventricular hypertrophy
● Echo LVH with EF 44%; mitral
regurgitation

13. Patient #2 Handoff Situation
What is going on
with the patient?
The patient is a 63 year who woke up this morning with severe
shortness of breath that has been worsening since.
Alarmed by the shortness of breath 911 was called and
paramedics have transported her here to the ER. They
placed an IV and gave a breathing treatment with
nebulized Combivent en route.
Background
What is the clinical
background or
context?
Patient felt fine last night before going to bed. She denies
chest pain, fever, chills, or lower extremity edema. There is
no prior history of similar problems.
Vital signs are:
Heart rate = 95
Blood Pressure = 190/130
Temperature = 37.1 °C
O2 sat on room air = 90%
Respiratory rate = 30
Assessment
What do I think the
problem is?
I’m not sure what is going on with the patient, so I called you.
Recommendation
What would I do to
correct it?
We need your team to see the patient now.

14. Patient #3
“I haven’t been able to catch my breath since
this morning”
HPI:
● Sharp pain on left side around the nipple
when I take a deep breath
● Long plane ride 2 days ago
● Pain in calf
● PMI: COPD
Initial PE:
● Lips cyanotic
● Sinus rhythm - Right axis deviation
● Lungs - Bilateral wheeze
HR: 110
BP: 90/60
SpO2: 84%
T: 99°
RR: 30
Other Cues:
● BNP = 450
● Cardiac markers WNL
● D-Dimer 1325
Chest angio-CT - partially recanulized
thrombus 25% obstruction

15. Patient #3 Handoff
Situation
What is going on
with the patient?
The patient is a 67 year old who was in the normal state of health until 4 hours
ago when shortness of breath began.The patient states: I haven’t been able to
catch my breath since this morning”. The dyspnea was worse with exertion and
with deep breathing. There is also noticeable sharp left-sided chest pain when
taking in deep breaths. The dyspnea became severe enough that 911 was
called and paramedics have now transported the patient to the Emergency
Room. Paramedics have placed an IV and have given a breathing treatment
with nebulized albuterol en route.
Background
What is the clinical
background or
context?
Patient’s vital signs are:
Heart Rate = 110
Blood Pressure = 90/60
Temperature (°F) = 99.0
O2 Sats (room air) = 84%
Respiratory Rate = 32
Assessment
What do I think the
problem is?
I’m not sure what is going on, I’m really worried.
Recommendation
What would I do to
correct it?
We need your team to see the patient.

16. Purpose is to reflect on the case and what happened in the
patients’ rooms
Reaction
Description
Analysis
Application
Debriefing

17. Reaction
“I’m interested to hear how you are feeling now that the
simulation is over”
Encourage participants to express their initial emotional
response and thinking.

18. Description
“Let’s start with the first case. Can the leader of this
case summarize for us how the team arrived at the
working diagnosis so that we are all on the same
page?”
Short 3-5 minutes report on a patient
Follow up: “What things did you do for the patient?”

19. Analysis
“What aspects of the case do you think you managed well
and why?”
“What aspects of the case would you want to change and
why”
“Are there any outstanding issues before we go to the next
case?”
REPEAT THE PROCESS with 2 other cases

20. Application
“To close, each of you state one new thing you have
learned from this simulation experience.”

21. Logistics
Prebrief
10 minutes
Handoff at patient #1’s
door way with discussion
5 minutes
Patient #1
20 minutes
Handoff at patient #2’s
door way with discussion
5 minutes
Patient #2
20 minutes
Patient #3
20 minutes
Handoff at patient #3’s
door way with discussion
5 minutes
Debrief

22. References
Chamberlain, N. R., Sexton, P. S., Hardee, M. R., & Baer, R. W. (2016). Resources Utilized by Preclinical
Medical Students During Patient Morning Rounds. Medical Science Educator, 26(3), 283-286.
Diemers, A. D., van de Wiel, M. W., Scherpbier, A. J., Heineman, E., & Dolmans, D. H. (2011). Pre‐clinical
patient contacts and the application of biomedical and clinical knowledge. Medical education, 45(3), 280-288.
Diemers, A. D., Wiel, M. W., Scherpbier, A. J., Baarveld, F., & Dolmans, D. H. (2015). Diagnostic reasoning and
underlying knowledge of students with preclinical patient contacts in PBL. Medical education, 49(12), 1229-
1238.
Eppich, W., & Cheng, A. (2015). Promoting excellence and reflective learning in simulation (PEARLS):
development and rationale for a blended approach to health care simulation debriefing. Simulation in
Healthcare, 10(2), 106-115.