BEUDAMED
    FDA Adverse Event Injury Summary report: N

    QUATTRODE

    MDR report key: 2930405 · Received January 22, 2013

    Report

    Report Number
    1627487-2013-05132
    Event Type
    Injury
    Date Received
    January 22, 2013
    Date of Event
    January 4, 2013
    Report Date
    January 4, 2013
    Manufacturer
    ST. JUDE MEDICAL - NEUROMODULATION
    Product Code
    LGW
    PMA / PMN Number
    P010032
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    TX, US
    Reporter Occupation
    NOT APPLICABLE

    Narratives

    Additional Manufacturer Narrative · 1

    SJM HAS LIMITED INFO RELATED TO THE PT'S MEDICAL HISTORY AND IS UNABLE TO FORM AN OPINION AS TO THE RELEVANCY OF THE PT'S HISTORY TO THE EVENT REPORTED. SJM DEFERS TO THE PT'S PHYSICIAN REGARDING MEDICAL HISTORY.

    Description of Event or Problem · 1

    DEVICE 2 OF 2. REFERENCE MFR REPORT#: 1627487-2013-05131. IT WAS REPORTED THE PT WAS IN A CAR ACCIDENT. SINCE THE ACCIDENT, THE PT HAS BEEN EXPERIENCING FACIAL STIMULATION. AN IMPEDANCE CHECK REVEALED LOW IMPEDANCE. X-RAYS WERE TAKEN AND THE PT IS SCHEDULED TO HAVE AN APPOINTMENT WITH HER DOCTOR ON A LATER DATE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    28888 QUATTRODE SCS LEAD LGW ST. JUDE MEDICAL - NEUROMODULATION 3146 57007

    Patients

    Seq Age Sex Outcome Treatment
    1 45 YR Required Intervention SCS IPG: MODEL: 3788| IMPLANT:| SCS EXTENSIONS: MODEL: 3386 (X2)| IMPLANT: