BEUDAMED
    FDA Adverse Event Injury Summary report: N

    PENTA

    MDR report key: 4202031 · Received October 21, 2014

    Report

    Report Number
    1627487-2014-23693
    Event Type
    Injury
    Date Received
    October 21, 2014
    Date of Event
    August 15, 2014
    Report Date
    September 26, 2014
    Manufacturer
    ST. JUDE MEDICAL - NEUROMODULATION
    Product Code
    GZB
    PMA / PMN Number
    P010032
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    TX, US
    Reporter Occupation
    NOT APPLICABLE

    Narratives

    Additional Manufacturer Narrative · 1

    UDI (DI): (B)(4). 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

    IT WAS REPORTED THE PT BENT OVER APPROXIMATELY 6 WEEKS AGO AND FELT A "POP". AS A RESULT, THE PT IS EXPERIENCING PAIN AT THE LEAD SITE. THE PT IS TO MEET WITH THE SJM REPRESENTATIVE AS THE NEXT COURSE OF ACTION.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    670310 PENTA SCS LEAD GZB ST. JUDE MEDICAL - NEUROMODULATION 3228 3280555

    Patients

    Seq Age Sex Outcome Treatment
    1 51 YR Other IMPLANTED:| SCS IPG: MODEL 3788