Simpson-Golabi-Behmel Syndrome With Developmental Challenges, Cardiac Monitoring and Daily Living Support
Mr. Kabir Wadhwa (a fictional name) is a 25 year old man from Panipat, Haryana, who lives with Simpson-Golabi-Behmel syndrome, a rare genetic condition that can affect growth, development, muscle strength and the heart. After his cardiology team confirmed that he was medically stable, his family arranged 12 weeks of structured home support through AtHomeCare. This case study explains how a home nurse, patient attendant, physiotherapist and occupational therapist worked with the family to build a predictable daily routine, keep his cardiac symptoms under careful observation and help Kabir take a more active part in his own care. His underlying condition continues to need lifelong specialist follow-up, and this article describes support, not a cure.
This is a fictional case study written for education. The clinical framework, assessments, care plan and outcome reflect real home healthcare practice. Only details from the documented case summary are shared. Where information was not available, this article says so instead of filling gaps with assumptions. Every patient is unique, and treatment decisions must always be made by qualified healthcare professionals.
Patient Background
Kabir lives in Panipat with his parents. His mother is his primary caregiver and his father supports her. He is unmarried and spends much of his day on home based computer activities, which he enjoys and manages at his own pace.
Two parts of his medical history shaped everything that followed. First, he has lifelong developmental challenges and needs help with several everyday activities. Second, he has a structural heart problem that requires regular cardiology monitoring. The specific details of his heart condition belong to his confidential medical records and are not described in this article. What matters for home care is that his heart needs watching, and that his family knows exactly which changes should be reported and how quickly.
Earlier medical history
During childhood, Kabir needed hospital evaluation because of developmental concerns and a cardiac abnormality identified during medical assessment. Since then, his care has been built around regular specialist review rather than emergency treatment. His medicines and cardiac treatment are decided only by his treating doctors.
What prompted the recent review
More recently, his family noticed that he became unusually tired during longer activities. This kind of change matters in anyone with a structural heart problem, so his doctors arranged a full cardiac review. The evaluation is described in the next section.
Baseline function before home care began
Before AtHomeCare became involved, Kabir was medically stable but needed family assistance every day. His parents reported that he could complete basic activities but required reminders and supervision for more complicated tasks. He became tired during prolonged walking and needed rest periods. The family wanted a structured home care routine that would support his independence without placing unnecessary physical strain on him.
In rare genetic conditions, the family is often the most accurate source of daily information. Kabir’s parents noticed the change in his activity tolerance before anyone else. That observation led to a proper cardiac review. Home care teams are trained to treat family observations seriously, because early changes in tiredness, appetite or routine are often the first sign that something needs medical attention.
Clinical Assessment and Diagnosis
Understanding Simpson-Golabi-Behmel syndrome
Simpson-Golabi-Behmel syndrome (SGBS) is a rare genetic condition. In most reported cases it follows an X linked inheritance pattern and is linked to changes in a gene called GPC3, which is why it affects males more often. People with SGBS can have larger body size and head size, characteristic facial features, skeletal differences, and sometimes findings in the heart, kidneys or abdominal wall. In childhood, specialists may also arrange screening for certain tumors associated with the condition.
Development varies widely. Some people with SGBS have typical intelligence, while others have mild or significant learning difficulties. Heart problems, including structural defects, are among the reasons specialists recommend ongoing cardiac surveillance. Because every person’s pattern is different, Kabir’s plan was built only around what was documented for him.
Kabir’s documented associated conditions
- Developmental difficulties
- Mild learning difficulties
- Reduced exercise tolerance
- Mild muscle weakness
- Fine motor coordination difficulties
- Intermittent fatigue
- Dependence on family for some daily activities
Home care assessment at intake
The home care assessment looked at ten areas. This was not a formality. Each area mapped to a specific risk in his documented condition, and each one guided a part of the daily plan.
| Assessment area | What the team looked at | Why it mattered in this case |
|---|---|---|
| Heart related symptoms | Tiredness with activity, breathing changes, any chest discomfort | SGBS can involve the heart, so symptom patterns guide when specialists should review him |
| Breathing pattern | Rate and effort at rest and during activity | New breathlessness can signal a cardiac or lung change and is never ignored |
| Pulse and blood pressure | Checked as required by the nursing plan | Creates a home baseline that specialists can compare against at every review |
| Activity tolerance | How long he could walk or stay active before needing rest | Reduced tolerance was a documented problem, so it decided how activities were paced |
| Fatigue | Timing and severity through the day | Fatigue was the family’s main concern and remains a monitored risk |
| Mobility | Indoor walking, transfers, outdoor mobility | Walking indoors was independent, but outdoor mobility needed help |
| Balance | Stability during walking and bathroom routines | Directly connected to fall prevention planning |
| Nutrition | Meals, fluids and weight | Poor intake and unexplained weight change are monitored risks in his plan |
| Personal care skills | Bathing, dressing, grooming | Defines exactly where help is needed and where independence can grow |
| Communication and routines | Ability to follow daily routines and instructions | He follows simple instructions better one step at a time, which shaped how the team communicated |
Functional status documented at intake
The following two lists come directly from the documented functional assessment.
Independent
- Eating
- Drinking
- Basic grooming
- Toileting
- Short distance indoor walking
- Simple personal activities
Needs supervision or assistance
- Bathing
- Dressing on tiring days
- Medication organization
- Outdoor activities
- Complex household tasks
- Appointment preparation
- Managing unfamiliar situations
Notice how specific this split is. Kabir was not described as fully dependent or fully independent. He could feed himself, walk inside the house and manage basic grooming, but bathing, dressing on tiring days and medication organization needed support. Writing the needs this precisely is what allows a care plan to give help only where it helps, and to protect independence everywhere else.
Recent Hospital Evaluation
After the family reported increased tiredness during longer activities, Kabir’s doctors arranged a routine cardiac review. No emergency cardiac procedure was needed. The evaluation included the following, each chosen for a specific reason.
- Physical examination: a general check of his overall condition and heart related symptoms.
- Electrocardiography (ECG): records the electrical rhythm of the heart.
- Echocardiogram: an ultrasound that shows the structure of the heart and how well it is pumping.
- Blood pressure monitoring: part of routine cardiac assessment.
- Oxygen saturation assessment: checks how well oxygen is reaching the body.
- Routine blood tests: a general health screen ordered by the treating team.
- Nutritional assessment: reviews intake, weight and dietary needs.
- Functional assessment: measures what he can safely do day to day.
After this review, Kabir was considered stable for home based support. His ongoing plan includes regular cardiology follow-up, prescribed cardiac treatment when indicated, routine health monitoring, nutritional support, physiotherapy, occupational and functional support, and regular developmental and medical reviews.
The home care team does not independently alter prescribed medicines or cardiac treatment. Prescriptions, dose changes and treatment decisions belong only to Kabir’s treating doctors. The home team’s role is observation, reminders, records and communication.
Why Home Healthcare Was Needed
Kabir did not need hospital care at this point. He needed something hospitals cannot provide: someone present in his daily life, watching the small changes, holding the routine steady and feeding accurate information back to his specialists. Six clinical reasons drove the decision.
1. Rare conditions need continuity, not occasional contact
SGBS can affect many body systems, and its course differs from person to person. Specialists see Kabir periodically. Daily changes happen at home. A structured home team bridges that gap without replacing specialist judgment.
2. The heart must not be left unwatched
With a structural heart problem, early signs such as increasing breathlessness, new swelling or falling activity tolerance need to be caught between cardiology visits. Daily observation at home turns scattered family worry into usable clinical information.
3. Structure reduces strain on family caregivers
His mother carried most of the daily load. A fixed routine with defined support spread the work, made the day predictable for Kabir, and gave his parents space to rest and plan.
4. Independence grows with the right kind of help
Helping with everything would have slowly reduced what Kabir could do himself. The plan helped only where he needed help and encouraged him to complete tasks independently whenever it was safe.
5. Medicines stay safe with reminders, not decisions
Medication organization was a documented difficulty. A pill organizer plus scheduled reminders protects adherence, while the rule that the home team never alters prescriptions protects safety.
6. Everyone must know routine from urgent
The plan separated planned reviews from emergencies from day one. Urgent symptoms were never to be handled by waiting for a routine home visit. That clarity is a safety feature.
Families in a similar situation can read our complete guide to home healthcare services in Panipat to understand how these decisions are usually made. To see how home teams track heart related changes over time, this overview of home based cardiac monitoring explains the same principles used in Kabir’s plan.
Home Care Plan by AtHomeCare
Four professionals formed Kabir’s core support team, each with a clearly separated role. Their work followed the existing instructions of his treating doctors at every step.
Home Nursing
The home nurse provided the clinical layer of the plan.
- Monitoring vital signs as required
- Observing breathing changes
- Monitoring fatigue and activity tolerance
- Checking for swelling
- Medication reminders, never medication decisions
- Maintaining daily health records
- Monitoring nutrition and hydration
- Reporting significant changes to the family
The nurse followed the instructions given by Kabir’s treating doctors. Families who need a similar clinical presence at home can learn more about our home nursing services.
Patient Attendant
The attendant provided hands-on daily living support with one standing rule: encourage independence whenever it is safe.
- Personal hygiene and bathing support
- Dressing assistance, especially on tiring days
- Meal support
- Safe mobility and supervised walks
- Keeping the daily routine on track
- Light household activities
- Appointment preparation
- Companionship
This role is delivered by our trained patient care takers (GDA) and sits within our wider patient care services.
Physiotherapy
Physiotherapy focused on maintenance, not aggressive training. Sessions worked on muscle strength, joint flexibility, balance, walking ability and functional endurance. Every exercise stayed within the limits recommended by his medical team.
This matters because Kabir had mild muscle weakness and reduced exercise tolerance. Stopping movement would have worsened both. Overdoing movement would have risked his heart. The safe path was gentle, regular, supervised activity. Learn more about home physiotherapy in Panipat and why regular movement matters in recovery.
Occupational Therapy
Occupational therapy worked on the skills that turn dependence into participation.
- Dressing and grooming practice
- Personal organization
- Fine motor activities
- Simple household tasks
- Task sequencing, taught one step at a time
- Safe movement around the home
Because Kabir followed simple instructions better when they were given one step at a time, every activity was broken into small, repeatable steps.
Doctor home visits
A doctor home visit could be arranged for reviewing new symptoms, general medical assessment, reviewing home care records, medication review, and coordination with specialist care. This spared Kabir unnecessary travel while keeping his doctors connected to what was happening at home. Read how our doctor home visit service works.
A doctor home visit is for planned review, not for emergencies. If a patient develops severe breathing difficulty, chest pain or fainting, the correct action is immediate hospital care, never waiting at home. For families whose loved ones need a higher level of support at home, such as oxygen or monitoring equipment, our ICU at home in Panipat service provides doctor guided setups.
Medical Equipment Used at Home
Depending on his doctor’s recommendations, the family kept simple, practical equipment at home. None of it was complex. Each item answered a specific documented risk.
| Equipment | Purpose in Kabir’s care | How it connected to his documented risks |
|---|---|---|
| Digital blood pressure monitor | Blood pressure checks as required by the nursing plan | Creates a home record his cardiologist can review |
| Pulse oximeter | Oxygen saturation checks as required | Helps track breathing related changes early |
| Digital weighing scale | Regular weight tracking | Unexplained weight change is a monitored risk in his plan |
| Pill organizer | Medication organization | Supports reminders without anyone changing prescriptions |
| Non-slip bathroom mat | Bathing safety | Reduces fall risk during assisted bathing |
| Walking support | Mobility aid, kept for the future | Used only if his doctors later recommend it |
Families setting up care at home can explore medical equipment rental in Panipat instead of buying items that may only be needed for a season.
Daily Care Routine
A predictable day is not a small thing for someone with developmental challenges and reduced exercise tolerance. Predictability lowers anxiety, makes reminders easier to follow and makes any deviation from the normal pattern visible to the care team. Kabir’s routine was fixed across four blocks.
Morning
- Check Kabir’s general condition
- Give prescribed morning medicines
- Assist with bathing and dressing
- Provide breakfast
- Complete gentle mobility exercises if approved
- Record any unusual symptoms
Afternoon
- Provide lunch and adequate fluids according to medical advice
- Encourage rest between activities
- Complete occupational or functional activities
- Monitor fatigue
- Support the medication routine
Evening
- Encourage a short supervised walk if approved
- Complete prescribed exercises
- Assist with personal care activities
- Review activity tolerance and symptoms
Night
- Provide dinner
- Give prescribed evening medicines
- Maintain a calm routine
- Check for unusual breathing difficulty, swelling or excessive fatigue
- Prepare the environment for safe sleep
Rest is built into this schedule on purpose. With reduced exercise tolerance, the risk is not only doing too much. It is also stacking activity on top of activity until the body quietly falls behind. Planned rest between blocks keeps the whole day achievable without strain.
12 Week Care Timeline
The timeline below describes how the documented plan was put into practice. Specific measurements, such as blood pressure readings or weights, were recorded in the daily home care log and reviewed with the family. They are not reproduced here because the shared case summary does not include individual values.
Baseline and safety setup
- Home assessment confirmed the intake findings: independent with eating, grooming and indoor walking, assisted with bathing, dressing on tiring days and medication routines
- Pill organizer and non-slip bathroom mat placed in use
- Daily log started: symptoms, meals, fluids, rest, exercises and any changes
- Family walked through the escalation rules: what is routine, what needs a doctor visit, what means emergency care
Routine establishment
- Morning to night schedule introduced exactly as planned
- Instructions practiced one step at a time
- Gentle mobility work begun only as approved by his medical team
- Attendant began encouraging Kabir to complete safe tasks independently
Therapy rhythm
- Physiotherapy and occupational therapy sessions settled into a regular cadence
- Occupational therapy focused on task sequencing for dressing, grooming and simple household tasks
- Nurse monitored fatigue through the day and adjusted activity pacing with rest periods
- Nutrition and hydration intake recorded daily
Review with the family
- Routine reviewed against the log with his parents
- Reminders adjusted so Kabir received fewer prompts where he was managing well
- Bathroom and walking safety rechecked
- Home records organized for sharing with his specialists at the next review
Consistency and involvement
- Therapy and self care practice continued without interruption
- Kabir involved in decisions about his own daily routine whenever possible
- Appointment preparation practiced as a step by step routine
- Family reported growing comfort with fatigue monitoring
Documented outcome
- Daily routine more consistent across the full week
- Regular participation in gentle physiotherapy and functional activities
- Greater involvement in simple personal care tasks with fewer reminders for some parts of the routine
- Family confident in monitoring fatigue and recognizing symptoms that required medical review
- Underlying condition unchanged, as expected: lifelong specialist follow-up continues
Risks Monitored and Escalation Rules
Every item in this table comes from the documented monitoring plan. The middle column explains what the team and family watched for. The right column states the response, so that no one ever had to guess under pressure.
| Warning sign | What was watched | Response |
|---|---|---|
| Increasing breathlessness | Breathing pattern at rest and during activity | Report to the family the same day; severe difficulty means emergency care |
| Chest discomfort | Any new or unusual chest discomfort | Urgent medical attention |
| Fainting | Any fainting or near fainting episode | Urgent medical attention |
| New swelling | Ankles, feet and legs | Report promptly; doctors decide the next step |
| Sudden reduction in activity tolerance | How much walking or activity he could manage | Report for specialist review |
| Excessive fatigue | Tiredness beyond his usual pattern | Record it, pace activities with rest, inform the family |
| Falls | Any fall, even without injury | Post fall observation and medical review |
| Poor food intake | Skipped meals or reduced fluids | Encourage intake, keep recording, report if it continues |
| Unexplained weight changes | Steady weight loss or gain on the scale | Report; doctors review |
| Changes in usual behavior or functioning | Confusion, withdrawal or new difficulties with familiar tasks | Report for medical review |
Severe breathing difficulty, chest pain, fainting or sudden deterioration requires urgent medical attention. Call emergency services or go to the nearest hospital immediately. Home healthcare supports recovery at home but does not replace emergency medical services, and urgent symptoms are never managed by waiting for a routine home visit.
For a deeper understanding of how trained teams separate routine change from danger, see our guide to early warning signs that need a nurse at home in Panipat. Because falls were one of Kabir’s monitored risks, the team also applied principles from our comprehensive fall prevention guide.
Family Education
Kabir’s mother and father were the constant presence in his life. The education plan aimed to make them safer and more confident observers, not to turn them into nurses. The family was advised to:
- Maintain regular cardiology appointments
- Follow prescribed medicines exactly, and never change medication without medical advice
- Monitor for new cardiac symptoms
- Allow adequate rest between activities
- Encourage safe independence rather than doing everything for him
- Use simple, step by step instructions
- Keep frequently used items within easy reach
- Maintain a safe and uncluttered home
- Seek urgent medical care for serious symptoms
The family was also encouraged to involve Kabir in decisions about his daily routine whenever possible. Being asked about his own day kept him engaged and made the routine something he followed by choice, not something imposed on him.
Related reading for families: how medication monitoring and management at home prevents the most common medicine errors, how nutrition and hydration monitoring supports recovery, and practical ways of keeping the home safe, reachable and uncluttered.
Clinical Outcome at 12 Weeks
After 12 weeks of structured home support, Kabir’s daily routine became more consistent. He participated regularly in gentle physiotherapy and functional activities. With repeated practice and supervision, he became more involved in simple personal care tasks and required fewer reminders for some parts of his routine. His family became more confident in monitoring fatigue and recognizing symptoms that required medical review.
Mobility and daily routine
Kabir continued to walk independently inside the home throughout the period. His routine became more consistent, with regular times for meals, medicines, rest, therapy and activities. Rest periods remained built into the day, protecting his activity tolerance rather than testing it.
Participation and therapy
He attended gentle physiotherapy and functional activities regularly. Occupational therapy practice, delivered in one step at a time sequences, helped him take on more of his own personal care. Fewer reminders were needed for some parts of his routine. These are functional gains, earned through repetition, not sudden changes.
Family feedback
His parents reported growing confidence in two specific skills: monitoring his fatigue honestly, and recognizing which symptoms needed medical review. This matters beyond 12 weeks. A family that knows what to watch is a safety system that stays in place for years.
What did not change
Simpson-Golabi-Behmel syndrome is a lifelong genetic condition. Kabir’s cardiac history continues to require long term specialist care. The improvements in this case were in daily organization, functional participation and caregiver confidence. No claim is made that home care altered the underlying condition, because it did not, and it was never designed to.
What improved: routine consistency, therapy participation, involvement in personal care, caregiver confidence. What stayed the same: the underlying genetic condition and the need for specialist cardiac follow-up. This is what realistic success looks like in home care for a rare genetic condition.
Key Clinical Learnings
- Build the plan around documented problems, not a template. SGBS can affect many systems, but Kabir’s plan focused on his actual documented needs: developmental support, cardiac observation, mobility and daily living help. Rare disease care works best when it is specific.
- The heart needs watching between hospital visits. Families and nurses learned to track breathing, fatigue, swelling and weight, so the cardiology team receives accurate home information at every review. Structured heart monitoring at home turns family observation into clinical data.
- Fatigue is information, not a mood. With reduced exercise tolerance, tiredness was treated as a signal. Activities were paced with planned rest instead of being pushed through or cancelled.
- One step at a time changed participation. Explaining tasks in single steps helped Kabir follow routines and gradually take on more of his own care. Communication style is part of the treatment.
- Simple tools prevent the most common home care errors. A pill organizer, a weighing scale and a daily log reduced missed medicines and made changes in appetite or weight visible early.
- Clear escalation rules protect patients. The plan separated routine review from emergencies from day one. Nobody had to decide under stress what counted as serious.
- Caregiver confidence is a clinical outcome. Educated families detect change earlier, communicate better with specialists and sustain safe care long after a formal care period ends.
- Home healthcare complements specialists. It never replaces them. Diagnosis, prescriptions and treatment decisions stayed with Kabir’s treating doctors throughout the 12 weeks.
Supporting Clinical Documents
The following records formed the evidence base for this case study. Identifying details are withheld and the patient’s name is fictional, in line with privacy standards.
| Document | Role in this case |
|---|---|
| Cardiology review notes | Findings from the recent review, including ECG, echocardiogram, blood pressure and oxygen saturation assessment |
| Routine blood test reports | General health screening ordered by the treating team |
| Nutritional assessment | Intake, weight and dietary needs |
| Developmental assessment | Longstanding developmental profile used to shape communication and routine design |
| Mobility and functional assessment | Walking ability and performance of daily activities |
| Home nursing daily records | Symptoms, vital signs when checked, medicines given, meals, fluids, rest and any changes |
| Physiotherapy session notes | Exercises performed and how he tolerated them |
| Occupational therapy notes | Task practice and progress in sequencing and self care |
| Family education checklist | Advice given to the family and their understanding of monitoring and escalation |
This article does not publish laboratory values, medicine names or imaging reports. Those belong to the patient’s confidential record. Where a specific value was not available in the shared case summary, this article states that it was not documented rather than guessing.
Frequently Asked Questions
1. What is Simpson-Golabi-Behmel syndrome?
Simpson-Golabi-Behmel syndrome is a rare genetic disorder that can affect growth, development and multiple organ systems. The features and level of support needed can vary between individuals. Most reported cases are linked to changes in a gene called GPC3 and follow an X linked inheritance pattern, which is why the condition is seen more often in males.
2. Why may cardiac monitoring be needed?
Some people with the syndrome can have heart abnormalities. Regular assessment allows the treating cardiologist to monitor heart function and manage any identified problems. In Kabir’s case, doctors reviewed his heart after his family noticed increased tiredness during longer activities.
3. Can home care cure Simpson-Golabi-Behmel syndrome?
No. It is a genetic condition. Home care focuses on supporting daily functioning, safety, therapy routines and management of associated medical needs. The genetic condition itself continues to need specialist medical care.
4. How can physiotherapy help?
Physiotherapy can help maintain strength, flexibility, balance and safe mobility when it is appropriate for the person’s medical condition. For Kabir, exercises stayed within the limits recommended by his medical team.
5. What should caregivers watch for?
Caregivers should watch for new or worsening breathlessness, chest discomfort, fainting, swelling, unusual fatigue, falls or a significant change in usual activity. Severe breathing difficulty, chest pain or fainting needs urgent hospital care.
6. Can adults with SGBS live at home?
Yes. Support needs vary considerably. Some adults may perform many activities independently, while others may need family or professional assistance with specific daily tasks. Kabir walked, ate and groomed independently at home and needed help with bathing, dressing on tiring days and medication routines.
7. What equipment did the family keep at home?
As per the doctor’s recommendations, the family kept a digital blood pressure monitor, a pulse oximeter, a digital weighing scale, a pill organizer and a non-slip bathroom mat. Walking support was kept as an option only if later recommended by his doctors.
8. How does a home care team work with specialist doctors?
The home team records daily observations, gives medicine reminders and reports significant changes to the family. It follows the instructions of the treating doctors and never changes prescribed medicines or cardiac treatment on its own.
9. When should a family seek urgent care instead of waiting at home?
Severe breathing difficulty, chest pain, fainting or sudden deterioration requires immediate medical attention. Routine matters, such as reviewing new symptoms or home care records, can be handled through a planned doctor home visit.
10. How was the daily routine adapted to Kabir’s learning needs?
Instructions were given one step at a time, tasks were kept predictable, and Kabir was involved in decisions about his own routine whenever possible. This helped him follow the plan and take part in his own care.
Home Care Goals and How the Plan Pursued Them
| Goal | How the plan worked toward it |
|---|---|
| Support safe independence in daily activities | The attendant helped only where needed and encouraged independent steps; occupational therapy built task sequencing skills |
| Monitor cardiac symptoms | The nurse tracked breathing, fatigue and swelling; blood pressure and saturation were checked as required |
| Maintain mobility and physical function | Gentle physiotherapy within the limits set by his medical team |
| Reduce fall risk | Non-slip bathroom mat, supervised walks, uncluttered spaces and a safe bathroom routine |
| Support adequate nutrition and hydration | Regular meals, fluids according to medical advice, daily intake records |
| Maintain a predictable daily routine | A fixed morning to night schedule with rest built into every block |
| Improve caregiver confidence | Family education, shared records and clear escalation rules |
| Coordinate home support with specialist care | Home records prepared for specialist reviews; treating doctors’ instructions followed exactly |
Contact AtHomeCare
Corporate Office
Unit No. 703, 7th Floor, ILD Trade CentreD1 Block, Malibu Town
Sector 47
Panipat, Haryana 122018
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Medical Disclaimer
Every patient is unique. Treatment decisions must always be made by qualified healthcare professionals based on the individual’s condition. Emergency symptoms require immediate hospital care. Home healthcare complements, but does not replace, emergency medical services.
This fictional case study is intended for educational purposes only. Simpson-Golabi-Behmel syndrome can present differently in each individual. Medical diagnosis, cardiac monitoring, medication, therapy and treatment decisions should always be made by qualified healthcare professionals based on the individual’s condition.