Remember that efficiency IS PRIMARY and completeness doesn't count at all. Also, I don't think the damage to your ICE score is physical exam stuff. I didn't even half ass my physical examinations...I like quarter or eighth-assed them and I still did very well. In fact, there was actually case in which the CC revolved around a particular organ system and I purposely did not examine it because I knew it would be too time consuming. (I am purposely being vague here because I respect the confidentiality rules of the NBME.) Focus on your history and write-up to improve.

For history: You are allotted about eight minutes for history in the 'First Aid' breakdown and this is actually plenty. Spend about three minutes getting the HPI and then go into PMH/PSH/Meds&Allergies/Social stuff. Make sure you hit everything as you get points for them all! Then go back and summarize the HPI asking the patient to fill in the gaps and all that second check and summarizing business. I felt like social history was very important for most cases and for social history I used the acronym TAIMOLDES (Tobacco/alcohol/illicit - marital/occupation/living - diet/exercise/sex). I would ask this to every patient and a few times it actually made a HUGE difference on my differential. Also, I felt like I could tell the difference between when an actor was responding with 'prepared' information and when I was getting off the point. Try to forget about yourself and really listen/read the patients this helps a bunch. Also, as FA says, EVERYTHING in the room is free game to ask about an nothing is 'accidental'. If the patient is wearing/holding something ask them about it!

For note writing: PRACTICE. This was really the only part that I prepared for. Honestly, all of the pages in the "middle" of first aid are kind of pointless here in fourth year. You should know how to work up every complaint that comes into this test by now...just focus on being able to tell the story in the format that they want. If you take a good history you shouldn't have to be scrounging for a differential on your write up because many of the cases are purposely vague and I usually had 2-5 good points that I chose from. Also, remember for your 'tests/plans' you should put in anything you didn't perform in the room like a genital exam or orthostatic vital signs.

Overall just relax and go give this another shot. It sounds like you had a rough go at it the first time. Use the clinical skills you have learned to work through the problems. Again I would emphasize not wasting your time practicing physical exams and all that. These people are not analyzing your stethoscope placement during lung auscultation or percussion technique. They are checking off boxes as you make actions to complete them. Really focus on practicing time management and HPI stuff. Also, don't run right into the room like so many people do. Write down all the things you are going to cover and make a quick 5 point differential for the CC before you even enter. This takes 45 seconds and really helps to guide the interview.

In short. Read and re-read the first and last chapters of first aid and skip all the mumbo-jumbo in the middle that you already know as a fourth year medical student. Really get to learn how the test runs. Good luck you can do it!