Citation Nr: 0005759 Decision Date: 03/03/00 Archive Date: 03/14/00 DOCKET NO. 95-04 123 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to a disability rating in excess of 40 percent for Reiter's disease, prior to August 24, 1998. 2. Entitlement to an increased disability rating for limitation of motion of the lumbar spine as a residual of Reiter's disease (lumbar spine disability), currently rated as 20 percent disabling. 3. Entitlement to an increased disability rating for limitation of motion of the cervical spine as a residual of Reiter's disease (cervical spine disability), currently rated as 20 percent disabling. 4. Entitlement to an increased disability rating for limitation of motion of the right shoulder as a residual of Reiter's disease (right shoulder disability), currently rated as 10 percent disabling. 5. Entitlement to an increased disability rating for limitation of motion of the left shoulder as a residual of Reiter's disease (left shoulder disability), currently rated as 10 percent disabling. 6. Entitlement to an increased (compensable) disability rating for nephritis. 7. Entitlement to service connection for hypertension, to include as due to service-connected nephritis. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Jonathan B. Kramer, Associate Counsel INTRODUCTION The veteran had active service from November 1955 to December 1957, and from November 1961 to October 1964. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions rendered in September 1994 and January 1995 by the Department of Veterans Affairs (VA) Regional Office in Cleveland, Ohio, (RO). The September 1994 rating decision denied entitlement to a disability rating in excess of 40 percent for Reiter's disease, and a compensable disability rating for nephritis. A notice of disagreement (NOD) was received in October 1994, a statement of the case (SOC) was issued in January 1995, and a substantive appeal (SA) was received in May 1995. Regarding the veteran's claim of entitlement to service connection for hypertension, which was denied pursuant to the January 1995 rating decision, a NOD was received in February 1995, a SOC was issued in May 1995, and a SA was received in May 1995. The Board notes that the veteran appeared and testified at an RO hearing in February 1996. The Board further observes that pursuant to a September 1998 determination, the RO recharacterized the veteran's 40 percent disability rating for service-connected Reiter's disease by separately rating each of the body parts affected by the chronic residuals of Reiter's disease, namely, by assigning a 20 percent rating for limitation of motion of the lumbosacral spine, a 20 percent rating for limitation of motion of the cervical spine, a 10 percent rating for the right shoulder, and a 10 percent rating for the left shoulder, all effective August 24, 1998. Inasmuch as the residuals of Reiter's disease is still considered the cause of these separate disabilities, and considering that the overall combined disability rating thereof was increased to 50 percent in accordance with 38 C.F.R. §§ 4.25, 4.26, the Board finds that the above-described rating action is not proscribed by 38 C.F.R. §§ 3.951, 3.952. Moreover, as the veteran has continued to express dissatisfaction with the newly assigned (increased) disability ratings, has otherwise not withdrawn his appeal for these increased disability ratings, and in light of the fact that the maximum schedular disability ratings have not been assigned to date, the appeal continues. AB v. Brown, 6 Vet. App. 35, 38 (1993). FINDINGS OF FACT 1. All relevant evidence necessary for an equitable resolution of the veteran's appeal has been obtained by the RO. 2. Prior to September 16, 1997, the medical evidence of record does not show that the veteran's Reiter's disease manifested weight loss and anemia productive of severe impairment of health, or severely incapacitating exacerbations occurring four or more times a year or a lesser number over prolonged periods. 3. The medical evidence of record shows that the veteran's Reiter's disease was ascertainably inactive as of September 16, 1997, but as of that date chronic residuals of Reiter's disease continued to be affect the cervical spine, lumbar spine, and both shoulders. 4. For the period September 16, 1997, through August 23, 1998, the service-connected chronic residuals of Reiter's disease resulted in severe limitation of motion of the cervical spine and the lumbar spine, and motion of both shoulders was limited to 90 degrees by pain. 5. For the period August 24, 1998, and thereafter, the veteran's service-connected chronic residuals of Reiter's disease have resulted in no more than moderate limitation of motion of the cervical spine and the lumbar spine, and motion of both shoulders has been limited to approximately 100 degrees by pain. 6. The positive evidence is in a state of equipoise with the negative evidence on the question of whether the veteran's hypertension is related to his service-connected nephritis. CONCLUSIONS OF LAW 1. The schedular criteria for a disability rating in excess of 40 percent for Reiter's disease were not been met prior to September 16, 1997. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5002 (1999). 2. For the period September 16, 1997, through August 23, 1998, the schedular criteria for a 40 percent disability rating for limitation of motion of the lumbar spine as a residual of Reiter's disease were met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5002, 5292 (1999). 3. For the period September 16, 1997, through August 23, 1998, the schedular criteria for a 30 percent disability rating for limitation of motion of the cervical spine as a residual of Reiter's disease, were met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5002, 5290 (1999). 4. For the period September 16, 1997, through August 23, 1998, the schedular criteria for a 20 percent disability rating for limitation of motion of the right shoulder as a residual of Reiter's disease was met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5002, 5200, 52011 (1999). 5. For the period September 16, 1997, through August 23, 1998, the schedular criteria for a 20 percent disability rating for limitation of motion of the left shoulder as a residual of Reiter's disease were met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.45, 4.59, 4.71a, Diagnostic Codes 5002, 5200, 5201 (1999). 6. For the period August 24, 1998, and thereafter, the schedular criteria for a disability rating in excess of 20 for limitation of motion of the lumbar spine as a residual of Reiter's disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5002, 5292 (1999). 7. For the period August 24, 1998, and thereafter, the schedular criteria for a disability rating in excess of 20 for limitation of motion of the cervical spine as a residual of Reiter's disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5002, 5290 (1999). 8. For the period August 24, 1998, and thereafter, the schedular criteria for a disability rating in excess of 10 for limitation of motion of the right shoulder as a residual of Reiter's disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5002, 5200, 5201 (1999). 9. For the period August 24, 1998, and thereafter, the schedular criteria for a disability rating in excess of 10 for limitation of motion of the left shoulder as a residual of Reiter's disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5002, 5200, 5201 (1999). 10. The veteran's hypertension is proximately due to or the result of his service-connected nephritis. 38 U.S.C.A. §§ 1110, 1131, 5107(a) (West 1991); 38 C.F.R. § 3.310 (1999); Allen v. Brown, 7 Vet. App. 439 (1995). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Increased Rating Claims The veteran claims that he has suffered an increase in the severity of his service-connected disabilities. When a veteran is seeking an increased rating, such an assertion of an increase in severity is sufficient to render the increased rating claim well grounded. 38 U.S.C.A. § 5107(a); Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). With a well- grounded claim arises a statutory duty to assist the veteran with the development of evidence in connection with his claim. 38 U.S.C.A. § 5107(a). After noting that the claims file includes the veteran's service medical records, VA examination reports, VA hospital discharge summaries, VA clinical records, private medical records, as well as the veteran's written statements and the February 1996 RO hearing testimony, the Board finds that the record as it stands is adequate to allow for equitable review of the veteran's increased rating claim and that no further action is necessary to meet the duty to assist the veteran. Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). A. Reiter's disease - Lumbar Spine, Cervical Spine and Shoulders Pursuant to an April 1958 RO rating decision, the veteran was granted service connection for Reiter's disease, and assigned a 30 percent disability rating, effective December 27, 1957. A February 1970 RO rating decision increased the veteran's disability rating to 40 percent effective September 3, 1969. In accordance with a March 1973 rating decision, the veteran's disability rating was decreased to 20 percent, effective June 1, 1973. A February 1986 rating decision increased the disability rating to 40 percent effective June 6, 1985. This 40 percent disability rating remained in effect until August 23, 1998, when, as discussed previously, the RO increased the veteran's overall disability rating for Reiter's disease pursuant to a September 1998 determination that separately rated all of the specific parts affected by the chronic residuals of Reiter's Disease. Looking to the record, VA outpatient reports dated in 1993, 1994 and 1994 do not show severe impairment of health due to symptoms associated with Reiter's disease. The veteran was routinely described as well-nourished and his weight was generally in the 165 to 170 pound range. Medical reports did not reference any findings of anemia. A January 1995 VA hospital discharge summary expressly noted that the veteran was not anemic. A September 1997 VA nephritis examination report included an impression of a "[h]istory of Reiter's disease, which is, at present, resolved." A contemporaneous VA hypertension examination report, outlined the veteran's history regarding his Reiter's disease. While in the service, the veteran underwent a long hospitalization for treatment of conjunctivitis, urethritis, and arthritis. The conjunctivitis and urethritis cleared up, but the arthritis has continued until the present. A VA joints examination report, dated September 16, 1997, revealed that the veteran complained of stiffness, pain, and swelling of the joints. Objectively, there was no evidence of swelling, deformity, instability, or subluxation of the joints. Range of motion of the shoulders was as follows: flexion was to 130 degrees, with pain starting at 90 degrees, bilaterally; extension was to 15 degrees, bilaterally; lateral flexion was to 10 degrees, bilaterally; right shoulder external rotation and internal rotation were to 10 degrees; left shoulder external rotation was to 15 degrees and internal rotation were to 20 degrees; abduction was to 120 degrees, with pain starting at 90 degrees, bilaterally; right shoulder adduction was to 15 degrees and left shoulder adduction was to 10 degrees. Range of motion of the elbows was noted to be limited to 110 degrees of flexion, bilaterally, while extension, pronation and supination were normal, bilaterally. Range of motion of the wrists was normal for extension and flexion, bilaterally, but radial and ulnar deviation was limited to 10 degrees, bilaterally. Range of motion of the hips was as follows: flexion to 90 degrees, bilaterally; extension to 20 degrees, bilaterally; internal rotation to 5 degrees and external rotation to 15 degrees, bilaterally; abduction to 40 degrees, bilaterally; adduction to 12 degrees, bilaterally. Range of motion of the knees was to 110 degrees of flexion, with normal extension, bilaterally. Range of motion of the ankles was to 20 degrees of flexion and 15 degrees of extension, bilaterally. Range of motion of the lumbar spine was limited to 30 degrees of flexion, 0 degrees of extension, and 10 degrees of lateral flexion, bilaterally. Range of motion of the neck revealed flexion to 10 degrees, extension "is almost nil,", and lateral flexion was to 25 degrees, bilaterally. The examiner commented "[t]here is severe restriction of movement of the neck, as well as the spine." The impression stated that there was a history of Reiter's syndrome with no objective findings at present, diffuse joint and muscular pain, and no evidence of conjunctivitis or urethritis. An August 24, 1998 VA orthopedic examination report indicated that the examiner had reviewed the veteran's prior medical examination. The veteran complained of pain in the multiple joints. Objectively, the veteran had a normal gait. On forward bending he could not touch his toes; range of motion of the lumbosacral spine showed flexion to 60 degrees, extension to 20 degrees, and right and left lateral flexion to 20 degrees. Cervical spine range of showed flexion to 30 degrees, extension to 40 degrees, right and left lateral extension to 30 degrees, and right and left rotation to 50 degrees. Range of motion measurements for the hips, knees, ankles, elbows, and wrists were full without pain. Range of motion of the shoulders was normal, except for limitation of flexion and abduction to 100 degrees, due to pain. The diagnoses were a history of Reiter's syndrome with apparent near complete remission, a positive HLA-B27 antigen in 1995, polyarthralgia, and a history of rheumatoid arthritis. The examiner opined that since the late 1950s, the veteran has had no recurrent episodes of Reiter's syndrome though he has continued to show a positive HLA-B27 antigen laboratory study which is associated with Reiter's syndrome and spondyloarthopathy. For all intents and purposes, it appears that he has a subclinical presentation of Reiter's syndrome where he maintains a positive abnormal laboratory test, HLA-B27 antigen, but he does not manifest any substantial objective abnormalities consistent with arthritic changes in the joints. Prior to August 24, 1998, the veteran's Reiter's disease was rated under 38 C.F.R. § 4.71a, Diagnostic Code 5002, as the RO determined that the manifested symptomatology was analogous to rheumatoid arthritis (atrophic), as an active process. The diagnostic criteria under this regulation provides for the following: a 100 percent evaluation is assignable for symptoms with constitutional manifestations associated with active joint involvement, totally incapacitating; a 60 percent evaluation is assignable for symptoms less than the criteria for 100 percent but with weight loss and anemia productive of severe impairment of health or severely incapacitating exacerbations occurring four or more times a year or a lesser number over prolonged periods; a 40 percent evaluation for symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring three or more times a year; and a 20 percent evaluation for one or two exacerbations a year in a well-established diagnosis. For chronic residuals, the appropriate Diagnostic Code is used for rating the specific joints affected. Where, however, the limitation of motion of the affected joints is noncompensable, a 10 percent rating assignment is appropriate when it is accompanied by objective confirmation of painful motion, swelling, or muscle spasm. In accordance with the RO's September 1998 determination that separately rated all of the specific parts affected by the chronic residuals of Reiter's disease, it was explained that August 24, 1998, was selected as the effective date because that was the date it was definitely ascertained that the veteran's Reiter's disease was inactive, pursuant to the findings reported in the August 24, 1998, VA orthopedic examination report, and upon application of 38 C.F.R. § 3.400 (a), (o). The Board finds, however, that medical evidence prior to August 1998 also shows that the veteran's Reiter's disease had been inactive prior to August 24, 1998. Specifically, two separate VA examinations, one conducted on September 16, 1997, specifically found that there was no objective evidence of Reiter's disease, or that the veteran's Reiter's disease had "resolved". Therefore, considering the totality of the circumstances, the Board reasons that the inactive status of the veteran's Reiter's disease can be shown back to September 16, 1997. Moreover, the Board finds that the VA joints examination report, dated September 16, 1997, reveals that the veteran exhibited much more severe limitation of motion of the cervical and lumbar spine than in August 1998. Prior to September 16, 1997, however, and going back to March 1994, when the veteran filed his current claim for an increased disability concerning his Reiter's disease, there is no medical evidence showing that the veteran suffered from symptoms of weight loss and anemia productive of severe impairment of health, or severely incapacitating exacerbations occurring four or more times a year or a lesser number over prolonged periods. Therefore, prior to September 16, 1997, the Board concludes that the preponderance of the evidence is against the veteran's claim for a disability rating in excess of 40 percent for Reiter's disease. As noted earlier, from September 16, 1997, and thereafter, it is appropriate that the veteran's spine and shoulder disabilities be rated separately pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5002, for the chronic residuals of Reiter's disease. The veteran's spine disabilities are rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5290 and 5292. Diagnostic Code 5290, which contains the diagnostic criteria for rating limitation of motion of the cervical spine, provides for a 30 percent disability rating for severe limitation of motion, 20 percent for moderate limitation of motion, and a 10 percent disability rating for slight limitation of motion. Diagnostic Code 5292, which contains the diagnostic criteria for rating limitation of motion of the lumbar spine, provides for a 40 percent disability rating for severe limitation of motion, 20 percent for moderate limitation of motion, and a 10 percent disability rating for slight limitation of motion. The September 16, 1997 VA joints examination report specifically stated that there was "severe restriction of movement" of the cervical and lumbar spine. Indeed, the measurements for range of motion of the cervical and lumbar spine did appear consistent with severe limitation of motion, thus warranting the assignment of a 30 percent disability rating for limitation of motion of the cervical spine and a 40 percent disability rating for limitation of motion of the lumbar spine. See 38 C.F.R. § 4.71, Diagnostic Codes 5290, 5292. With regard to the shoulders, Diagnostic Code 5201, provides for the following: a 40 percent disability rating if range of motion is limited to 25 degrees from the side (30 percent for a minor joint); a 30 percent disability rating if range of motion is limited to midway between the shoulder and the side (20 percent for minor joint); and 20 percent disability rating if range of motion is limited to shoulder level (20 percent for minor joint). The Board observes that VA examination of the shoulders on September 16, 1997, showed flexion to 130 degrees and abduction to 120 degrees. However, the examiner reported that there was pain at 90 degrees. The Board notes that 90 degrees is essentially shoulder level. Applying the regulatory provisions regarding additional functional loss due to pain as outlined in 38 C.F.R. § 4.40, 4.45, the Board believes that the shoulder range of motion was effectively limited to shoulder level at the time of the September 16,l 1997, examination so as to warrant a 20 percent rating for each shoulder under Diagnostic Code 5201. The Board has also notes that the September 16, 1997 VA examination report also includes range of motion testing for various other joints. However, upon application of the appropriate diagnostic codes for such joints, no compensable limitation of motion was exhibited. Moreover, although there was noncompensable limitation of motion exhibited in these joints, there were no objective observations of painful motion, swelling, or muscle spasm, that would justify a 10 percent disability rating for chronic residuals of Reiter's disease. To summarize, the Board finds that for the time period September 16, 1997, through August 23, 1998, the following disability ratings are warranted: 40 percent for limitation of motion of the lumbar spine; 30 percent for limitation of motion of the cervical spine; and separate 20 percent ratings for each shoulder. These disability ratings are assignable because they provide for a combined disability rating in excess of the 40 percent disability rating heretofore assigned by the RO for the period September 16, 1997, through August 23, 1998. See 38 C.F.R. §§ 4.25, 4.26, Concerning whether the present disability ratings assigned for the cervical spine, lumbar spine, left shoulder, and right shoulder should be increased, for the period August 24, 1998, and thereafter, the August 24, 1998, VA examination report is the most recent piece of medical evidence that addresses these issues. In regard to the issues of limitation of motion the cervical and lumbar spine subsequent to August 23, 1998, it is evident that the respective range of motion measurements are significantly less limited (improved) in the August 1998 examination report, when compared to those recorded in the September 1997 VA examination report. The Board agrees with the RO in its determination that 20 percent disability ratings, representing no more than moderate limitation of motion, are consistent with the range of motion measurements recorded in August 1998. With respect to the disability ratings assigned for each shoulder, the Board observes that the August 24, 1998, examination showed normal flexion and abduction but with flexion and abduction limited to 100 degrees by pain. This evidence, therefore, shows that the criteria for the 20 percent rating were no longer met as of that dated. However, since there was some limitation of motion with pain, 10 percent ratings are nevertheless warranted from that date. The Board again notes that in evaluating the severity of the foregoing disabilities, the application of 38 C.F.R. §§ 4.40, which allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements (See DeLuca v. Brown, 8 Vet. App. 202 (1995)), and 38 C.F.R. § 4.45, which provides that consideration be given to weakened movement, excess fatigability, and incoordination, have been contemplated. The Board also finds, as did the RO, that the evidence of record does not present such "an exceptional or unusual disability picture as to render impractical the application of the regular rating schedule standards." 38 C.F.R. § 3.321(b)(1). In this regard, the Board has considered the history of the veteran's disabilities, the current clinical manifestations, and the effect these disabilities may have on the earning capacity of the veteran under 38 C.F.R. §§ 4.1, 4.2, and finds that there has been no showing by the veteran that his Reiter disease residuals have resulted in marked interference with his employment or necessitated frequent periods of hospitalization. In the absence of such factors, the Board finds that the criteria for submission for assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Finally, to the extent that the veteran was not granted the relief sought as to the issues addressed above, the Board has considered the provisions of 38 U.S.C.A. § 5107(b), but there is not such a state of equipoise of the positive evidence and the negative evidence to otherwise permit a favorable resolution of the present appeal. II. Service Connection for Hypertension The veteran claims service connection for hypertension, to include as due to service-connected nephritis. As this issue involves a claim of entitlement to service connection, the applicable law provides that service connection will be granted if it is shown that the veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Further, where a veteran who served for ninety (90) days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic conditions, such as cardiovascular disease (including hypertension), or arthritis (including degenerative joint disease, i.e., osteoarthritis), to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, service connection may be granted for a disorder found to be proximately due to, or the result of, a service-connected disability, including on the basis of aggravation. 38 C.F.R. § 3.310; Allen, 7 Vet. App. at 439. However, it should be noted at the outset that statutory law as enacted by the Congress charges a claimant for VA benefits with the initial burden of presenting evidence of a well- grounded claim. 38 U.S.C.A. § 5107(a). A well-grounded claim has been defined by the Court as "a plausible claim, one which is meritorious on its own or capable of substantiation." Murphy v. Derwinski, 1 Vet. App. 78, 91 (1990). The Board finds the service connection for hypertension claim to be well-grounded on a secondary service connection basis. In this regard, while there is no express medical opinion of record suggesting that the veteran's hypertension is related to his already service-connected nephritis, the Board takes administrative notice of the fact that the VA regulation which sets forth the criteria for evaluating nephritis (38 C.F.R. § 4.115a, Diagnostic Code 7502), includes reference to hypertension as a symptom or manifestation to be considered. The Board views this as a recognition by the VA as a government agency that a medical relationship has been found to exist (at least to some degree) between nephritis and hypertension. This certainly makes a claim on a secondary basis plausible. Turning to the merits, the Board observes that various VA hospital discharge summaries and treatment records, for the period January 1995 to February 1999, include hypertension diagnoses, and show that the veteran received continuing treatment and monitoring for his hypertension. A September 1997 VA hypertension examination report recounted the veteran's cardiac history, and noted that the veteran was not diagnosed with hypertension until 1993; the diagnoses included hypertension. And as was mentioned earlier, a September 1997 VA nephritis examination report stated that kidney function was observed to be normal, and that it was unlikely that the veteran's hypertension was caused by service-connected nephritis. The remaining evidence consists of the veteran's variously dated written statements and February 1996 RO hearing testimony, which contend that his hypertension is related to his service-connected nephritis. It appears at first glance that the evidence or record does not support a finding of any causal relationship between the veteran's service-connected nephritis and his hypertension. In fact, a trained medical professional has opined that there is most likely no such relationship. On the other hand, VA has recognized that there is some type of relationship by couching certain diagnostic criteria in terms of the degree of hypertension shown. Under these circumstances, the Board believes that a reasonable doubt must be found to be present with regard to the underlying question of whether or not the veteran's hypertension is due to his nephritis. Under these circumstances, such reasonable doubt is to be resolved in the veteran's favor. 38 U.S.C.A. § 5107(b). ORDER For the period September 16, 1997, through August 23, 1998, a 40 percent disability rating for limitation of motion of the lumbar spine, as a residual of Reiter's disease, is warranted. For the period September 16, 1997, through August 23, 1998, a 30 percent disability rating for limitation of motion of the cervical spine, as a residual of Reiter's disease, is warranted. For the period September 16, 1997, through August 23, 1998, a 20 percent disability rating for limitation of motion of the right shoulder, as a residual of Reiter's disease, is warranted. For the period September 16, 1997, through August 23, 1998, a 20 percent disability rating for limitation of motion of the left shoulder, as a residual of Reiter's disease, is warranted. Entitlement to service connection for hypertension secondary to nephritis is warranted. To this extent, the appeal is granted. A disability rating in excess of 40 percent for Reiter's disease, prior to September 16, 1997, is not warranted. For the period August 23, 1998, and thereafter, a disability rating in excess of 20 for limitation of motion of the lumbar spine, is not warranted. For the period August 23, 1998, and thereafter, a disability rating in excess of 20 for limitation of motion of the cervical spine, as a residual of Reiter's disease, is not warranted. For the period August 23, 1998, and thereafter, a disability rating in excess of 10 for limitation of motion of the right shoulder, as a residual of Reiter's disease, is not warranted. For the period August 23, 1998, and thereafter, a disability rating in excess of 10 for limitation of motion of the left shoulder, as a residual of Reiter's disease, is not warranted. To this extent, the appeal is denied. REMAND The remaining issue involves the veteran's claim that a compensable rating for his service-connected nephritis is warranted. As discussed above, service connection has been found to be warranted on the basis that it is secondary to the nephritis. The Board takes notice that specific regulations govern disability evaluations when nephritis and hypertension are involved. See 38 C.F.R. §§ 4.115, 4.115a. As such, the issue of entitlement to an increased rating for nephritis is not intertwined to some degree with the question of evaluating the newly service-connected hypertension. Appropriate preliminary action by the RO is therefore called for. Accordingly, this matter is hereby REMANDED to the RO for the following actions: 1. Any pertinent VA medical records (not already in the claims file) documenting ongoing or recent treatment for nephritis and/or hypertension should be associated with the claims file. 2. After accomplishing any additional development deemed necessary by the RO, the RO should review the record and determine the appropriate disability rating(s) to be assigned for nephritis and hypertension in view of the Board's finding that the veteran's hypertension is due to his service-connected nephritis. The veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded an opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. The purpose of this remand is to ensure preliminary rating action by the RO in view of the grant of service connection for hypertension secondary to nephritis. The veteran and his representative are free to submit additional evidence and argument in support of the issues addressed by the Board in this remand. ALAN S. PEEVY Member, Board of Veterans' Appeals