The employee c/o hives which began about 36 hours after receiving a HEPATITIS B vaccine and a seasonal inactivated influenza vaccine on 10/6/09 about 9 am.  The hives began the evening of 10/7/09 at approximately 8-9 PM.  The hives were predominately located on her back.  She states that the rash was itchy.  She denies any associated difficulty breathing, shortness of breath, mouth or tongue swelling.  She denies any new foods, soaps, detergents.  She has been taking BENADRYL 2-4 X a day (denies drowsiness other than on the first day), PREDNISONE 60 mg - tapering doses that was prescribed by a PA and ZYRTEC.  She was also evaluated by Dr. - she denies any prior h/o hives.  Allergies - none known.  PE - very faint erythematous macular rash upper abdomen, chest arms and back - the rash is not diffuse.  There is slight facial erythema.  No urticaria is visible.  Imp - / allergic reaction to hepatitis B vaccine and/ or inactivated seasonal influenza vaccine.  Plan - continue present medications - taper PREDNISONE.  File VAERS Observe.  The employee returns stating that after completing her course of PREDNISONE on 10/18, she had almost complete resolution of the hives.  However, since 10/25, the hives have returned.  The symptoms come and go and are not associated with any particular food or activity although she did have a few episodes in the evening while sitting on the couch and a few times while in bed during sexual activity.  However, the hives also occur sporadically during the day. She has been self-medicating with ZYRTEC and BENADRYL and recently tried CLARITIN with no relief.  She does have cats and dogs, but has always been around pets.  She is unable to identify any new food, medication, soaps, etc.  She does not eat shellfish.  She has not had any oral swelling, shortness of breath, or respiratory difficulty during these episodes.  Meds- birth control pill.  PE- alert, NAD, no respiratory distress.  VS BP 130/86 P-87 T-99 po pulse oximter 99% on room air.  Skin - there are scattered areas of urticaria on the arms and trunk.  Dematographism is present on the right lower forearm, volar surface in an area where the patient scratched.  Mouth - no swelling of oral mucosa or lips.  Impression - urticaria of unknown etiology.  These episodes started 36 hours after she received a hepatitis B vaccine and a seasonal influenza vaccine on 10/6/09.  It is unlikely that the urticaria is secondary to the vaccination because of the amount of time that elapsed between the receipt of the vaccines and the onset of the urticaria, however a VAERS has been filed.  Plan - trial of ALLEGRA 60 mg orally twice daily.  Refer to allergist for further evaluation and work-up if symptoms continue.  I reminded her to discontinue the use of all other antihistamine - type medications such as ZYRTEC, CLARITIN and BENADRYL while taking ALLEGRA.  I also asked the employee to keep a journal of when the episodes occur and the foods she eats as well as activities.  I recommended that she switch to Dove soap for showers and use a hypoallergenic laundry detergent.  She should discontinue the use of any fabric softeners or dryer sheets.  Note - review of pre-placement evaluation done on 9/29/09 prior to hiring the employee reveals that the employee was taking AMOXICILLIN 500 mg tid in anticipation of having a wisdom tooth removed on 10/2/2009.  She did have the wisdom tooth successfully removed and completed her seven day course of AMOXICILLIN on 10/5/09 at 10 am, one day prior to the receipt of the hepatitis B vaccine and the inactivated seasonal influenza vaccine.  The employee was taking an occasional ibuprofen for residual tooth pain when she received the vaccine.  She was not acutely ill.  She has no known allergies.