BEUDAMED
    FDA Adverse Event Injury Summary report: N

    PENTA

    MDR report key: 3010667 · Received March 14, 2013

    Report

    Report Number
    1627487-2013-03371
    Event Type
    Injury
    Date Received
    March 14, 2013
    Date of Event
    February 4, 2013
    Report Date
    February 20, 2013
    Manufacturer
    ST. JUDE MEDICAL - NEUROMODULATION
    Product Code
    LGW
    PMA / PMN Number
    P010032
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    TX, US
    Reporter Occupation
    NOT APPLICABLE

    Narratives

    Additional Manufacturer Narrative · 1

    SJM HAS LIMITED INFORMATION 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

    IT WAS REPORTED THE PT EXPERIENCED A FALL AND SUBSEQUENTLY IS NOT RECEIVING STIMULATION ON HER RIGHT SIDE. IT WAS ALSO REPORTED THE PT'S SCS LEAD HAS MIGRATED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    108333 PENTA SCS LEAD LGW ST. JUDE MEDICAL - NEUROMODULATION 3228 3511111

    Patients

    Seq Age Sex Outcome Treatment
    1 41 YR Required Intervention IMPLANT DATE:| SCS IPG: MODEL 3788