In that case I'd stick it to 0x AA, 16x AF, FXAA on, texture high, blur high, shadow medium, decal ultra, water to reflect land and skies only, object fade 7, light fade 25, actor fade 7, item fade 7, grass fade 4, specularity fade 20, distant detail high, object fade on.
If the shadows look too ugly though, try opening your SkyrimPrefs.ini and change fShadowBiasScale= to 0.2500. That will have a minor impact on performance but will do more good than harm. On medium the shadows are really pixelated but changing that will blur out the edges and make them look more real.
EDIT: Forget that, it's BlurDeferredShadowMask= that you need to change, and put it on around 7. The BiasScale is still useful though as it can stop the weird chase effect Skyrim has with shadows where as you run forward the shadows kinda run from you. It's hard to explain.
BlurDeferredShadowMask (note that the shadows on the right are on ultra, medium is a huge step down, so you'll benefit even more from the setting)
This is shadow bias:
TBH, the only things that let Skyrim down on looks on lower settings are the shadows so this should sort it out for you, good luck.
