MRCP2-0350
A 68-year-old man presents to the emergency department complaining of shortness of breath. He has been experiencing worsening palpitations since being diagnosed with a chest infection by his GP two days ago and starting oral antibiotics. He feels very unwell and severely short of breath. The patient has a history of myocardial infarction, AF, and type 2 diabetes mellitus. On examination, he has a heart rate of 167 bpm, blood pressure of 87/50 mmHg, oxygen saturations of 93% on 5 litres of oxygen, and a temperature of 36.5ºC. He appears very unwell and distressed with bilateral crepitations to his mid-zones and peripheral edema to his thighs. His ECG shows atrial fibrillations. What is the most appropriate immediate management?