BEUDAMED
    FDA Adverse Event Injury Summary report: N

    PENTA

    MDR report key: 3960906 · Received July 22, 2014

    Report

    Report Number
    1627487-2014-12492
    Event Type
    Injury
    Date Received
    July 22, 2014
    Date of Event
    June 15, 2014
    Report Date
    June 27, 2014
    Manufacturer
    ST. JUDE MEDICAL -NEUROMODULATION
    Product Code
    GZB
    PMA / PMN Number
    P010032
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CA, US
    Reporter Occupation
    NOT APPLICABLE

    Narratives

    Additional Manufacturer Narrative · 1

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

    Description of Event or Problem · 1

    DEVICE 4 OF 4. REFERENCE MFR REPORT #1627487-2014-12489. REFERENCE MFR REPORT #1627487-2014-12490. REFERENCE MFR REPORT #1627487-2014-12491.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    427237 PENTA SCS LEAD GZB ST. JUDE MEDICAL -NEUROMODULATION 3228 3878148

    Patients

    Seq Age Sex Outcome Treatment
    1 66 YR Other IMPLANT DATE:| SCS ANCHORS, MODEL 1194 (2)| SCS IPG, MODEL: 3688 (2)| IMPLANT DATE: